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

2. 

4. Remember to complete a separate form for each 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. Best Management Practices (BMP) Trained*

    1. Yes
    2. No

19. BMP Certified Person

20. Upload Picture of BMP Certification Card

22. Owner/Company Name*

23. Reg. Agent Name

25. Address*

26. Address2

28. City*

29. State*

30. Zip*

32. Owner 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 FSE*
    -- 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 EasternOtherSouthernSpanishThaiTurkishVeganVegetarianVietnamese

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 the Yellow Grease Container Information

48. Yellow Grease Container on-site? *

    1. Yes
    2. No

50. Yellow Grease Rendering Co./Person

51. Phone Number

53. Enter the GCD Information

55. Grease Control Device (GCD) in FSE?*

    1. Yes
    2. No

57. Location

58. Select all that Apply

    1. Exterior Interceptor
    2. Interior Floor
    3. Interior Under Sink

59. Size

61. Check One

    1. Gallons/minute
    2. Pounds
    3. Gallons

62. Manufacturer

63. Model

65. Cleaning Service Co./Person

66. Phone

68. Cleaning Frequency
    -- Select One --WeeklyBi-weeklyMonthlyBi-monthlyQuarterlyBi-annuallyAfter each useOther

69. Other

70. Upload GCD Equipment Photo

72. Certification
    I hereby certify that I am the owner/authorized representative to make entries and that the information on this sheet it correct. Any falsification, misrepresentation, or misleading information VOIDS this registration form.

    I hereby certify that I am the owner/authorized representative to make entries and that the information on this sheet it correct. Any falsification, misrepresentation, or misleading information VOIDS this registration form.

74. Signature *

    Type name

75. Date*
    Date

79. Thank you for keeping Norfolk sewers grease free!
    Visit our FOG page for more information.

    Norfolk Department of Utilities - Division of Water Quality

81. Address: 6040 Waterworks Rd., Norfolk, VA 23502
    O: 757-441-5678 ext. 229 M: 757-620-2688 Fax: 757-441-5639 Email: UTFOG@norfolk.gov

    O: 757-441-5678 ext. 229 M: 757-620-2688 Fax: 757-441-5639 Email: UTFOG@norfolk.gov

83. Water and Sewer Main Break 24-HR Emergency 757-823-1000

Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit Submit and Print

* indicates a required field