FOG Abatement Program Waste Discharge Permit Application

2. Physical Address
3. Mailing Address (If different from above)
4. Designated Facility Contact Name
Address
5. Designated Contact for Permit / Permit Fees
(if different from Designated Facility Contact)
Address
6. Is the building owned or leased?(Required)
7. Building Owner
If the building is leased, provide the following information.
Address

Section B — Food Service Establishment Category

Food Service Establishment Category(Required)
Choose the option below that best describes your facility.

Section C

Facility Operation
See instructions on page ___ of ____________.pdf
2. Hours and Meals
Complete the chart below for your normal hours of operation and the number of meals or customers served. Please add lines as necessary to cover each day your operation serves meals.
Day of the Week
Hours of Operation
Total Hours Open
Approx. # of Meals Served
 
Provide any additional information to supplement the chart above. This may include a seasonal nature of operations, annual functions, or other variations from a normal schedule.
4. Indicate the number of the following kitchen appliances and fixtures currently located at your facility.
7. As an effort to keep grease out of the drains and sewer system, has a kitchen Best Management Practices program been instituted?

Section D — Grease Control Devices

Section 19 of the Rules and Regulations of the Albemarle County Service Authority requires each food service establishment, existing or new, to install a grease control device(s) in an effort to minimize the grease discharged to the ACSA wastewater collection system.
1. Complete the charts below for the grease control device(s) currently located at your facility. See the instructions (page ___ of _____________.pdf) for the distinction between the two types of devices. Please add as many lines as you need. Note: This does not refer to the recycled grease container you may use, and is collected periodically by the service company.
Grease Traps
Device Name
Location
Size (gallons or dimensions)
Serviced by
Cleaning frequency
 
Grease Interceptors
Device Name
Location
Size (gallons or dimensions)
Serviced by
Cleaning frequency
 
2. Is there any type of solids screen or solids interceptor installed (other than the standard sink baskets
4. Is there a flow control value for each grease trap?
5. Is there any bacterial or biological enzyme additive placed in the plumbing, grease trap(s), or grease interceptor(s)?
6. If you answered yes to #5, complete the following chart and attached a Safety Data Sheet for each product.
Additive Name
Location of Use
Amount and Frequency of Use
 

Section E — Authorized Signature

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 persons 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.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

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