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2. FORM 1: PERMIT COMPLIANT PRETREATMENT SYSTEM
4. IF YOU CURRENTLY HAVE A CLASS 3 OR 4 FOOD SERVICE LICENSE FROM NCDHD- PLEASE ANSWER QUESTIONS 1 THROUGH 5.
6. By completing this section you are certifying that your FOG pretreatment meets all requirements of "FOG fact Sheet 2" or FOG Fact Sheet 3".
8. YOU MUST ATTACH TWO YEARS OF MAINTENANCE RECORDS TO THIS SUBMISSION.
10. MAINTENANCE RECORDS
12. If you have an external in-ground tank, the next pump-out must be witnessed by the grease inspector. Please call 860-253-5246 or 860-253-6450 to schedule this inspection.
14. ALL FACILITIES WILL BE INSPECTED AND THE INSPECTION FEE IS $50.00. RE-INSPECTIONS WITHIN 30 DAYS ARE FREE.
18. Facility Name:*
19. Legal Owner's Name:
20. Facility Address:*
21. Phone number:*
23. Email Address:*
27. QUESTION 1
29. Please complete the following for EACH installed grease trap. If you do not have a grease trap, indicate "No grease trap" in MANUFACTURER field.
31. GREASE TRAP #1
33. Manufacturer:
34. Size:
35. Passive/Automatic

    1. Passive
    2. Automatic
36. Indoor/Outdoor

    1. Indoor
    2. Outdoor
38. Location:
39. Please select the option which best describes how often this grease trap is cleaned:
    -- Select One --DailyEvery Six MonthsMonthlyQuarterlyBi-WeeklyNever Clean ItWeeklyYearlyOther
40. If "Other", please explain:
42. GREASE TRAP #2
44. Manufacturer:
45. Size:
46. Passive/Automatic

    1. Passive
    2. Automatic
47. Indoor/Outdoor

    1. Indoor
    2. Outdoor
49. Please select the option which best describes how often this grease trap is cleaned:
    -- Select One --DailyEvery Six MonthsMonthlyQuarterlyBi-WeeklyNever Clean ItWeeklyYearlyOther
50. If "Other", please explain:
54. QUESTION 2
56. If you have an indoor grease trap (AGRU), how do you dispose of the waste after cleaning the trap?

    PLEASE SELECT ONLY ONE:

    1. Trash
    2. Mix with other grease stored on premises(i.e. fryolator grease)
    3. Contractor/Licensed Renderer
60. QUESTION 3
62. Licensed Rendered Company Information:
    If a Licensed Rendered Company Maintains your AGRU, please provide the following information:
64. Renderer Name:
65. Renderer Phone#
69. QUESTION 4
71. If waste fats, oils and grease are stored on the premises from fryolators or other sources, where is this material stored?

    1. Inside Building
    2. Outside Building
75. QUESTION 5
77. If an outdoor, in-ground grease trap is utilized, list the name and telephone number of the company who pumps out the grease interceptor:
79. Company Name:
80. Company Phone #:
84. IF MORE THAN TWO GREASE TRAPS ARE INSTALLED, PLEASE SUBMIT ANOTHER FORM AND PROVIDE INFORMATION ON THE OTHER GREASE TRAPS AT YOUR FACILITY.
86. (August 2016)
Leave This Blank:


88. 1. Receive an email copy of this form.
89. Email address

    This field is not part of the form submission.

90. Submit Submit and Print

* indicates a required field