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IV. Location <br />Information <br />Location Information <br />Specialty Type <br />(Check One) <br />(Check One) <br />❑Catering <br />❑American -Burger <br />❑Hospital <br />❑Bagel <br />❑Hotel <br />❑Bakery <br />❑Mall/Food Court <br />❑Barbecue <br />❑Nightclub/Bar <br />❑Cafeteria/Buffet <br />❑Prison <br />❑Chicken <br />❑School <br />❑Chinese <br />❑Stadium/Amusement Park <br />❑Coffee Shop <br />❑Stand-alone Restaurant <br />❑Cookie <br />❑Strip-Mall/Attached <br />❑Deli/Sandwich <br />❑Supermarket <br />❑Doughnut <br />❑Other <br />❑French <br />❑Greek <br />V. FOG Sources VI. UPC <br />Oils <br />Meats <br />(One or More) <br />(One or More) <br />❑Butter <br />❑Beef <br />❑Lard <br />❑Chicken <br />❑Margarine <br />❑Pork <br />❑Peanut Oil <br />❑Seafood <br />❑Shortening <br />❑Vegetable Oil <br />VII. Lateral Line <br />Clean Out <br />Lateral Cleanout Location <br />Dice Cream <br />❑Indian <br />❑Italian <br />❑Japanese/Sushi <br />❑Korean <br />❑Meat/Carniceria <br />❑Mexican <br />❑Pizza <br />❑Seafood <br />❑Steakhouse <br />❑Vegetarian <br />❑Vietnamese <br />❑Other <br />Seating <br />(Check One) <br />❑Sit-down <br />❑Take-out <br />❑Combo <br />Chain Status(Check <br />One <br />❑Chain <br />❑Independent <br />Inside Seating Capacity <br />Outside Seating Capacity <br />During Peak Hours: # of Meals Served per Hour <br /># of Employees working <br />Non -Disposable Dish Usage ❑ Yes ❑ No <br />Significant Use of Pots and Pans❑ Yes ❑ No <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 <br />Approximate Gallons <br />Pick-up Frequency <br />❑<55 ❑56-150 <br />❑Twice a month <br />Yellow Grease Disposal Documentation <br />Date of Last Pick-up <br />5u <br />❑Quarterly ❑Semi -Annually <br />19 F -2 / 9 Page 2 of 4 <br />