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2. 
4. Enter Identifying Food Service Establishment (FSE) Information
6. FSE Name*
8. Address*
9. Apt./Unit
10. Zip*
12. Enter Yellow Grease (used cooking oil) Disposal Information
14. By law, records must be retained on-site for at least three years.
16. Disposal Date*
    Disposal Date
18. Disposed by*
    Company name
20. Approximate Volume Removed*
    Pounds/gallons
22. Yellow Grease Container (used cook oil) Before Photo
23. Yellow Grease Container (used cook oil) After Photo
24. Yellow Grease Container (used cook oil) Before Photo2
    Optional
25. Yellow Grease Container (used cook oil) After Photo2
    Optional
27. 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.
29. Signature*
    Type name
30. Date*
    Date
32. Thank you for keeping Norfolk sewers grease free!
    Visit our FOG page for more information.

    Norfolk Department of Utilities - Division of Water Quality
34. 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
36. Water and Sewer Main Break 24-HR Emergency 757-823-1000
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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field