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2. 
4. Enter Identifying FSE Information
6. FSE Name*
8. Address*
9. Apt./Unit
10. Zip*
12. GCD Location*
    -- Select One --ExteriorFloorUSOther
13. Other
15. Enter GCD Cleaning Information
17. Max amount of grease + solids (25% capacity):
    By law, records must be retained on-site for at least three years.
19. Date Cleaned*
    Date Cleaned
21. Cleaned By*
    Company or person
23. A. Grease*
    Amount removed in inches
24. B. Solids*
    Amount removed in inches
25. C. Total Depth (no air)*
    This is the total of ALL liquids and solids (water + grease + solids, amount removed in inches)
27. Calculation
    Grease (A) plus (+) Solids (B) divided by (/)Total (C) multiply by (X) 100 = Percent (%) of FOG
29. Percent of FOG*
    A + B / C x 100 = % FOG
31. GCD Photo Before Cleaning
32. GCD Photo After Cleaning
33. GCD Photo Before Cleaning Photo2 (optional)
34. GCD Photo Before Cleaning Photo2 (optional)
36. Pump Out Invoice
    For GCD units > 50 gpm/100 lbs.
38. Certification
    I hereby certify that I am the owner/authorized representative to make entries to this maintenance log and that the information on this sheet it correct. Any falsification, misrepresentation or misleading information VOIDS this maintenance log.
40. Signature*
41. Date*
    Date
43. Thank you for keeping Norfolk sewers grease free!
    Visit our FOG page for more information.

    Norfolk Department of Utilities - Division of Water Quality
45. 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
47. Water and Sewer Main Break 24-HR Emergency 757-823-1000
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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

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