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2. Business Name*
3. Contact at business
5. Address*
6. Address 2
8. City*
9. State*
10. Zip code*
12. Phone
13. Email
15. Grease Interceptor Service Company Name
17. Attach service receipt (.pdf or .jpg)*
    Receipt must be included. Please do not leave spaces in your filename (example-yes.pdf and ExampleYes.jpg).
21. Please provide your contact information, if different from above.
23. Your Name
24. Your Email
26. Your Phone
30. Grease interceptor measurement (optional)
    Please use inches for all measurements
32. 
34. Chamber 1 grease depth
35. Chamber 2 grease depth
37. Chamber 1 solid depth
38. Chamber 2 solid depth
40. Liquid depth of grease interceptor
41. Gallons removed
43. Grease interceptor condition

    1. Functional

    1. Needs repair
45. Additional Comments
47. Date pumping occurred
    Date pumping occurred
48. Frequency of pumping for this location
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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field