THIS SECTION TO BE FILLED OUT BY CONTRACTOR

OWNER:

CONTRACTOR:

DUMP SITE:

ADDRESS:

MAP/LOT

COMMERCIAL RESIDENTIAL

DATE:

TANK SIZE

TANK MATERIAL

FIELDS

GREASE TRAP

DEPTH TO COVER

________

________

(CIRCLE ONE) FIELDS - DRY WELLS - GALLEYS - UNKNOWN

YES / NO

___________

GALLONS PUMPED -

EFFLUENT BACKFLOW

CONDITION OF TANK -

SCUM - _______INCHES

CONDITION OF BAFFLES

___________

YES - NO

SLUDGE -______INCHES

INLET: OK NG OUTLET: OK NG