Gray Water Return Authorization Form - City Of St. Petersburg

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ENVIRONMENTAL COMPLIANCE DIVISION
GREASE MANAGEMENT PROGRAM
Gray Water Return Authorization Form
1.
Facility Name: ___________________________________________________
Facility Address: __________________________________________________
Street: ___________________________________________________________
City: __________________________
State: ___________
Zip: ________
2.
Designated facility contact:
Name: __________________________________________________________
Title: _____________________________________________________________
Telephone number: ______________________________________________
3.
Grease Hauler Name: ____________________________________________
Address: ________________________________________________________
City: __________________________ State: ____________
Zip: ________
Telephone number: _______________________
I certify that I have read Section 27-227(d)(3) of the St. Petersburg City Code and
understand that I shall utilize a grease hauler who has been permitted by the City for pumping
services. Pumping services shall include the initial complete removal of all contents, including
floating materials, wastewater and bottom sludges and solids from the interceptor. Additionally, I
understand that the return of gray water back into the interceptor from which the wastes were
removed is allowed, provided the grease and solids are not returned to the interceptor.
I further certify under penalty of law that this document was 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 on my inquiry of the person or persons who
manage the system, or those persons directly responsible for gathering the information, the
information submitted, 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.
Name: _________________________________________
Title:
____________________________________________
_____________________________________
__________________________
Signature
Date
A copy of this document must be retained on file and available for review.

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