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Grease Control Device (GCD) Cleaning Log

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.

    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

    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.

    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

    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

Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

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