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IV. Location <br />Information <br />Location Information <br />Specialty Type <br />Seating <br />(Check One) <br />(Check One) <br />(Check One) <br />❑Catering <br />❑American -Burger ❑Ice Cream <br />❑Sit-down <br />❑Hospital <br />❑Bagel ❑Indian <br />❑Take-out <br />❑Hotel <br />❑Bakery ❑Italian <br />❑Combo <br />❑Mall/Food Court <br />❑Barbecue ❑Japanese/Sushi <br />❑Nightclub/Bar <br />❑Cafeteria/Buffet ❑Korean <br />❑Prison <br />❑Chicken ❑Meat/Carniceria <br />Chain Status(Check <br />❑School <br />❑Chinese ❑Mexican <br />One <br />❑Stadium/Amusement Park <br />❑Coffee Shop ❑Pizza <br />❑Chain <br />❑Stand-alone Restaurant <br />❑Cookie ❑Seafood <br />❑Strip-Mall/Attached <br />❑Deli/Sandwich ❑Steakhouse <br />❑Independent <br />❑Supermarket <br />❑Doughnut ❑Vegetarian <br />❑Other <br />❑French ❑Vietnamese <br />❑Greek ❑Other <br />V. FOG Sources <br />VI. UPC <br />Oils Meats <br />Inside Seating Capacity <br />(One or More) (One or More) Outside Seating Capacity <br />❑Butter ❑Beef <br />During Peak Hours: # of Meals Served per Hour <br />❑Lard ❑Chicken <br /># of Employees working <br />❑Margarine ❑Pork <br />Non -Disposable Dish Usage ❑ Yes <br />❑ No <br />❑Peanut Oil ❑Seafood <br />Significant Use of Pots and Pans[-] Yes ❑ No <br />❑Shortening <br />❑Vegetable Oil <br />VII. Lateral Line <br />Clean Out <br />Lateral Cleanout Location <br />Additives Used <br />Is an additive being used? ❑ Yes ❑ No Type: ❑Biological ❑Chemical ❑Unknown <br />If Yes, List product name MSDS ❑ Yes ❑ No <br />Purpose (One or More): ❑ Odor Control ❑ Line Cleaning ❑Grease Interceptor ❑Other <br />Laterals <br />Lateral Cleaning Frequency ❑Twice a month ❑Monthly ❑Quarterly ❑Semi -Annually <br />❑Annually ❑Other <br />Contractor Name <br />Vill. Yellow Grease Disposal (Waste Hauling) <br />Recycler Name <br />❑Drum ❑Bin ❑5 Gallon Container ❑Other <br />Approximate Gallons ❑<55 ❑56-150 ❑>150 <br />Pick-up Frequency ❑Twice a month ❑Monthly ❑Quarterly ❑Semi -Annually <br />Yellow Grease Disposal Documentation <br />Date of Last Pick-up <br />Page 2 of 4 <br />