Form Center

2. Business Name*
3. Email Address*
5. Who Cleaned The Trap*
6. Phone Number*
7. Date of Cleaning*
9. Location of Grease Trap *

   1. Under Sink
   2. In-Floor
11. Estimated Waste Thickness & Volume Removed from Trap
13. FOG Layer:*
14. Bottom Solids: *
16. Total Device Depth: *
17. Volume Pumped: *
19. The Contents of the Trap Were Discarded In: *

    1. Trash Dumpster
    2. Grease Waste Disposal Facility
21. Grease Trap Condition:
23. Walls & Bottom in Good Condition:*

    1. Yes
    2. Needs Repair
24. Baffles & Flow Control Device Intact *

    1. Yes
    2. Needs Repair
25. Cover & Gasket in Good Condition*

    1. Yes
    2. Needs Repair
27. If disposed at a Grease Waste Disposal Facility, attach a copy (pdf or jpg) of the dump ticket. The dump ticket must include the Facility Name, Address, Invoice or Control Number, Date & Time, and Name of Operator receiving the waste.
29. Dump Ticket
31. The City of Belleview must receive a date-stamped picture of before and after cleaning the trap. Submissions that do not include picture evidence will not be accepted.
33. Before Cleaning Trap *
35. After Cleaning Trap*
37. Certification *

    1. I certify that by checking this box and signing below all information listed above is true and accurate. I further certify the grease trap was thoroughly cleaned and no removed FOG or solid waste was returned to the trap or the collection system. I understand that falsification of information may be a violation of the City of Belleview’s Sewer Use Ordinance 86-225, and I may be subject to enforcement action.
39. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 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) you may still be required to provide a traditional signature at a later date.

    1. I agree.
41. Electronic Signature*
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field