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2. Waste Hauler Information
4. Hauler/Pumping Company*
6. Name*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
16. Vehicle Tag Number*
17. Tank Capacity (Gallons)*
19. Customer Information
21. Business/Company*
23. Address*
25. City*
26. State*
27. Zip Code*
29. Type of Device at Location*
31. Interceptor, Trap, and OWS Condition
33. Baffle Unobstructed & Intact*

    1. Yes
    2. Needs Repair
    3. Not Applicable
34. Cover Accessible, In Good Condition & Secure*

    1. Yes
    2. Needs Repair
36. Outlet & Inlet Pipes Intact*

    1. Yes
    2. Needs Repair
37. Walls & Bottom in Good Condition*

    1. Yes
    2. Needs Repair
39. Detail Repair Items
40. Date Pumped*
    Date Pumped

    Date Pumped
42. Estimated Waste Thickness & Volume Removed from Interceptor, Trap, & OWS Device
44. Oil/Grease (Inches)*
45. Bottom Solids (Inches)*
46. Total Depth (Inches)*
47. Volume Pumped (Gallons)*
49. Discharge Approval

    On the dates and times stated below, the wastes listed on this tracking form were approved for discharge, and were disposed by the hauler at the following permitted disposal/treatment facilities

51. Facility Name & Address*
53. Waste Received On*
54. Time*
56. Invoice Number*
57. Operator Name*
59. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) this information is correct an accurate, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) grease trap may be inspected at any time.

    I further certify the device listed above was thoroughly pumped and cleaned and no removed waste was pumped back into the device or into the collection system. I understand that falsification of information may be a violation of the City’s Code of Ordinances as outlined by the City’s Code of Ordinances adopted by Resolution by the City of Belleview (owners of the waste water collection system) and I may be subject to enforcement action resulting in fines of violation in accordance with Section 86-225. 

    1. I agree.
61. Customer Name*
62. Driver Name*
64. Electronic Signature*
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field