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1.
Food Service Establishment Contact Information(current) This section is complete This section is incomplete
2.
Food Service Establishment Information This section is complete This section is incomplete
3. Grease Interceptor This section is complete This section is incomplete

Food Service Establishment Contact Information

Facility Name*
Facility Location*
Facility Owner*
Facility Contact Name*
Facility Contact Title*
Facility Contact Phone Number*
Facility Contact Email*
Mailing Address*
City*
State*
Zip*
CERTIFICATION STATEMENT
The undersigned agrees they have personally examined and are familiar with the information submitted in this document and attachments. Based upon the inquiry of individuals immediately responsible for obtaining the information reported herein, the undersigned certifies, under penalty of law, that the submitted information is true, accurate and complete. The undersigned is aware that there are significant penalties for submitting false information.
Printed Name*
Printed Title*
Date*
Date
Contact for additional information:
Industrial Pretreatment Program
PO Box 5503, Bismarck ND 58506-5503
Telephone: 701-355-1763 or 701-355-1768
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4) Grease Interceptor
If it is determined that a grease interceptor is required, an appropriately sized interceptor is essential for preventing grease from entering the sanitary sewer system. Please complete the following.
Single Compartment Sink
Quantity
Double Compartment Sink
Quantity
Triple Compartment Sink
Quantity
Mop Sink
Quantity
Dishwasher
Quantity
5) Grease Trap Sizing:
When installing a grease trap, the following sizing guidelines are recommended. The volume of the fixtures connected to the grease trap should not exceed two and one half times in gallons per minute of the grease trap. The following table provides the criteria that should be considered for grease trap sizing:
Grease Trap Sizing Criteria
(if grease interceptor variance is approved)
Rate of Flow (in gpm):      20     25     35     50
Grease retention capacity in pounds:      40     50     70     100
Maximum allowable fixture volume in gallons:      50     62.5     87.5     125
How many gallons of water does the ware wash sink hold?
To determine the fixture cubic content:
Multiply the length x width x height in inches, x number of compartments. Divide this number by 231 to convert to gallons.
6) Indicate size and type of grease removal device that you propose to install.

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