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Food Service Establishment (FSE) Grease Control Device (GCD) Registration Form

2. 
4. Remember to complete a separate form for each Grease Control Device (GCD) in your establishment.
6. Enter the Food Service Establishment (FSE) Information
8. FSE Name*
9. FSE Street Address*
10. FSE Zip Code*
12. FSE Phone*
13. FSE Email*
15. Contact Name*
16. Contact Phone*
18. HR FOG Best Management Practices (BMP) Certified*

    1. Yes
    2. No
19. BMP Certified Person
20. Upload Picture of HR FOG BMP Certification Card
22. Owner/Co. Name*
23. Other
25. Address*
26. Address2
28. City*
29. State*
30. Zip*
32. Owner/Co. Phone*
33. FSE Location*

    1. Separate/Detached
    2. Mall/Complex
34. NAICS Number
    -- Select One --311812 Commercial Bakery312120 Brewery445110 Supermarket/other Grocery Store445120 Convenience Stores447110 Gas Station w/ Convenience Store624120 Adult Day Care Center624410 Child Day Care Center711110 Theater Companies w/ Dinner Theater721110 Traveler Accommodations (Hotels/Motels)722310 Cafeteria Food Service Contractors (e.g. government office, hospital cafeterias, school cafeterias)722320 Caterers (Banquet Halls w/ catering staff)722330 Food Carts, Mobile722410 Drinking Places (Alcoholic Beverages: Bars)722511 Full-Service Restaurants722513 Limited-Service Restaurants (Fast Food & Cafes)722514 Cafeterias, Grill Buffets, and Buffets722515 Snack & Non-Alcoholic Beverage Bars: Coffee, juice, ice cream, bagels, donuts, candy, etc...& at fixed locations813110 Churches, synagogues, Mosques, Temples, etc...
36. Type of Food Service Establishment*
    -- Select One --BakeryBreweryBuffetCafeCafeteriaChurch/ReligiousCoffee House/ShopCommunity KitchenConfectioneryConvenience StoreDay CareDinerFast FoodFood CartFood ManufacturerFood Truck/MobileFull ServiceGroceryHotel/MotelMarketNoneOtherPizzeriaSandwich/SoupSchool/InstitutionSports GrillSteakhouseTapasTea HouseWinery
37. Other
39. Type of Cuisine
    -- Select One --AmericanCaribbeanChineseCubanEastern EuropeanFilipinoFrenchGermanGreekIndianJapaneseKoreanLatin AmericanMexicanMiddle EasternOtherSeafoodSouthernSpanishThaiTurkishVeganVegetarianVietnamese
40. Other
42. Food *

    Mark all that apply

    1. Dairy
    2. Eggs
    3. Fish/Seafood
    4. Crabs
    5. Fruits
    6. Grains/Beans
    7. Nuts
    8. Meat/Poultry
    9. Vegetables
    10. Beverages
    11. Juices/Smoothies
    12. Bread/Baked items
44. Other Foods
46. Enter Used Cooking Oil (Yellow Grease) Recycling Information
48. Will the FSE be frying foods?*

    1. Yes
    2. No
49. Location of Used Cooking Oil (Yellow Grease) Storage Container/Tank
    -- Select One --Interior ExteriorOther
50. Other:
51. Is the Used Cooking Oil (Yellow Grease) Container shared with other FSEs?
    -- Select One --YesNo
53. Indirect Grease Hauler (Used Cooking Oil Removal Company)
54. Phone Number
56. Enter the Grease Control Device (GCD) Information
    Grease Control Device (GCD) shall mean a device used to collect, contain, or remove food waste and grease from the wastewater while allowing the remaining wastewater to be discharged to the City/County/Town’s sanitary sewer system by gravity. Devices include: hydromechanical grease interceptors(HGI), automatic grease removal devices (AGRD), or gravity grease interceptors (GGI).
58. Is there a GCD located inside or outside of the FSE?*

    1. Yes
    2. No
60. Where is the GCD located?
61. Select all that Apply

    1. Exterior Interceptor
    2. Interior in the Floor
    3. Interior Under the Sink
62. Size
64. Check One

    1. Gallons Per Minute (GPM)
    2. Pounds
    3. Gallons
65. Manufacturer
66. Model
68. GCD Cleaning Service Company/Person
69. Phone
71. Cleaning Frequency
    -- Select One --WeeklyBi-weeklyMonthlyBi-monthlyQuarterlyBi-annuallyAfter each useOther
72. Other
73. Upload GCD Equipment Photo
75. Certification
    I hereby certify that I am the owner/authorized representative to make entries and that the information on this sheet is correct. Any falsification, misrepresentation, or misleading information VOIDS this registration form.
77. Signature *
    Type name
78. Date*
    Date
82. Thank you for keeping Norfolk sewers grease free!
    Visit our FOG page for more information.

    Norfolk Department of Utilities - Division of Water Quality
84. 6040 Waterworks Rd., Norfolk, VA 23502
    Call or Text: 757-620-2688 Fax: 757-441-5639 Email: fog@norfolk.gov
86. Water and Sewer Main Break 24-HR Emergency (757) 823-1000
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89. 1. Receive an email copy of this form.
90. Email address

    This field is not part of the form submission.

91. Submit Submit and Print

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