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2. 
4. Quarterly Grease Trap Report (Fill in the Year)*
6. Time Frame*

   Check the quarter for the report you are filing.

   1. Quarter 1 = January-March. Due no later than April 10th
   2. Quarter 2 = April-June. Due no later than July 10th
   3. Quarter 3= July-September. Due no later than October 10th
   4. Quarter 4=October-December. Due no later than January 10th
10. Name of Establishment*
12. Address*
14. Phone Number*
15. Fax Number
17. Email Address*
19. Name of Responsible Party*
21. Do you have a waste oil bin/dumpster/receptacle?*

    1. Yes
    2. No
22. If yes, Upload an invoice here

    Note: Missing information will result in an incomplete submission and may result in non-compliance on your part. 

24. Do you share a waste oil bin/dumpster/receptacle with another restaurant?*

    1. Yes
    2. No
26. How many gallons of waste oil does it hold?*
27. How often is waste oil picked up?*
28. Name of waste oil hauler*
29. Please submit proof of hauler*
31. Address of waster oil hauler*
32. Phone Number of waste oil hauler*
36. Name of company/store/vendor where you purchase your grease trap bioenzyme treatment...*
37. Treatment Used:*
38. Submit Invoice/Proof*
40. Supplier's Address*
42. Supplier's City*
43. Supplier's State*
44. Supplier's Zip Code
46. Supplier's Phone Number*
47. Supplier's Fax Number
51. Name of the company that cleans out your grease traps.*
52. Submit Invoice/Proof*
54. Supplier's Address*
56. Supplier's City*
57. Supplier's State*
58. Zip Code
60. Supplier's Phone Number*
61. Fax Number
65. How many grease traps are located in your establishment?*
66. Name of grease trap treatment*
68. Is your grease trap treatment applied manually or automatically?*
69. How often is your grease trap treatment dispensed?*
71. Where are the grease traps located. Please list specific locations.*
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit Submit and Print

* indicates a required field