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Compliance Report - Professional Cleaning

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  2. Please check reporting period this compliance report is being submitted.*
  11. Grease Trap Maintenance

  17. Gallons

  19. Gallons

  21. Gallons

  28. 8. Is a copy of the grease trap service statement attached to this compliance report?
  31. Grease Trap Maintenance Observation Log

    All maintenance events must be observed by a Permit Holder staff member. The staff member must complete the maintenance observation log at the time of the maintenance event. The data entries must be handwritten and must be recorded in permanent ink.

  36. 2. Did the waste hauler remove the entire contents from the trap, including buildup on walls?
  37. 3. Did the waste hauler re-introduce any of the removed contents back into the trap after cleaning?
  39. 4. Did you receive a copy of the liquid waste hauler's service statement for your records?
  41. 5. Were you notified of any defects or items that are in need of repair or replacement?
  44. Certification Statement:

    This statement must be signed by the authorized designated signatory of the facility.

    I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

  46. Print name and title

    48. Leave This Blank:

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