Fillable WAS E SU VEY - PE MI APPLICATION (City of Hendersonville)

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WAS E SU VEY - PE MI APPLICATION (City of Hendersonville)

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  • 134 check-boxes
  • 38 other fields

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WAS
T
E SU
R
VEY - PE
R
MI
T
APPLICATION
–
FOOD
SERVICE ESTABLISHMENTS
1
This form is used to determine types and sources of wastewater that your business could be
discharging to the Hendersonville Wastewater Treatment Facilities. Failure to submit this form is
in violation of the City’s Sewer Use Ordinance and Chapter 52 of the Code of Ordinances.
Copies of the Sewer Use Ordinance are available upon request during regular business hours Monday
through Friday at the City Operations Center located at 305 Williams Street. If you have any
questions or concerns while completing this form, please contact Gracie Erwin at (828) 697-3057 or
eerwin@hvlnvc.gov
.
SECTION I
Food Service Establishment Information
(Please
Print)
Establishment Name:
Establishment Location Address: Phone:
Establishment Mailing Address:
Zip:
Owner Name: Phone:
Contact Person(s) or Manager(s) Responsible for Day-to-Day Operation and Management of
Business (if different from Owner).
Contact or Manager (1) Phone:
Name(s)
(2) Phone:
District Headquarters - Corporate Information
Business Name: Contact:
Address: Zip:
Telephone(s):
WASTE SURVEY - PERMIT APPLICATION – FOOD
SERVICE ESTABLISHMENTS
2
This Food Service Establishment is:
(Please
check)
An Existing Food Establishment; since (year)
New Construction
Renovation or change of ownership of existing Food Establishment
Renovation of Non-Food Establishment building
If Renovation of Non-Food Service Establishment building, list former use of building
if known:
SECTION II
1. How many employees does your food establishment employ?
2. What meals do you or will you serve?
(Please check
all that apply)
Breakfast Lunch Dinner
3. What are your operating hours?
4. How do you classify your business?
(Please
check all that apply)
Fast Food Fine Dining Bar & Grill Cafeteria
Bakery Delicatessen Caterer Coffeehouse
Food Processor Meat Processor Restaurant Cafe’
Institution Food Court Diner
Carryout Supermarket Other:
5. Which of the following menu items does your establishment serve?
(Please
circle all that apply)
Burgers Fried Potatoes Mexican Cuisine Fried Chicken
Oriental Cuisine Fried Fish Grilled/Baked Foods
Barbeque Sandwiches/Subs Pastries
WASTE SURVEY - PERMIT APPLICATION – FOOD
SERVICE ESTABLISHMENTS
3
Other Fried Foods:
6. Are menu items pre-cooked or baked off-site?
(
Please
check one)
All Some None
Examples:
7. Is disposable flatware utilized in your establishment?
(Please check
one)
Yes No Not Applicable
SECTION III
Does your establishment have any of the following?
(Please
check one)
1. Used Fryer Oil/Grease Recycling Bins: 0 1 2 3 4
a. Who picks it up?
b. How often is it picked up?
2. Number of Grease Traps Installed: 0 1 2 3
a. Trap capacity gallons gallons gallons
b. How often is trap(s) cleaned out?
(Please
check)
Twice-a-week Weekly Every 2 weeks
Monthly Every 2 Months Quarterly
Every 4 Months Biannually Annually
3. Who cleans it out?
(Licensed cleaning company is required if trap is not under sink mounted unit.)
WASTE SURVEY - PERMIT APPLICATION – FOOD
SERVICE ESTABLISHMENTS
4
4. What date was it last cleaned?
(Example
3/4/02)
5. Where is grease trap located? (If you are facing the front of the store)
Back Parking Area
Front Parking Area
Left Parking Area
Right Parking Area
Back Sidewalk
Front Sidewalk
Left Sidewalk
Right Sidewalk
Drive-in Area
Inside Under Sink
Inside in Floor
SECTION IV
Please check number of fixtures:
1.
Automatic Dishwasher
0
1
2
3
2.
Garbage Disposal
0
1
2
3
3.
3-Compartment Sink
0
1
2
3
4.
2-Compartment Sink
0
1
2
3
5.
Single Compartment Sink
0
1
2
3
6.
Pot Wash Sink
0
1
2
3
7.
Mop Wash Sink
0
1
2
3
8.
Food Prep Sink
0
1
2
3
9. Number of Floor Drains in Food Preparation Area
(Please
fill-in)
SECTION V
Please check amount of equipment:
Griddles
0
1
2
3
4
5
Grills
0
1
2
3
4
5
6
Fryers
0
1
2
3
4
5
6
Wok Stoves
0
1
2
3
4
5
Soup Kettle
0
1
2
3
4
5
WASTE SURVEY - PERMIT APPLICATION – FOOD
SERVICE ESTABLISHMENTS
5
Authorized Representative is defined as a person responsible for the principal business decisions or
other policy decisions for the facility.
This is to be signed by an Authorized Representative of your firm, as defined in the City
of Hendersonville Sewer Use Ordinance after completion of this form.
I certify under penalty of law that this document and all
attachments
were prepared under my
direction or supervision in accordance with a system designed to assure that qualified
personnel
properly
gather and
evaluate
the
information
submitted. Based upon my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the
information,
the
information
submitted is, to the best of my
knowledge
and belief, true, accurate
and complete. I am aware that there are significant penalties for submitting false information,
including
the
possibility
of fine and
imprisonment
for
knowing
violations.
Signature: Date:
Print Name: Phone Number:
Title:
Return this form within 30 days to:
Environmental Compliance Coordinator
Hendersonville Water and Sewer
305 Williams Street
Hendersonville, NC 28792
Or email the completed form to eerwin@hvlnc.gov
FAILURE TO RETURN THIS FORM MAY RESULT IN ENFORCEMENT ACTION IN
ACCORDANCE WITH THE CITY OF HENDERSONVILLE SEWER USE ORDINANCE!
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Completed 3 August 2020

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