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Date Due
Date Performed *
Licensed Sanitary Disposal Contractor *
Pumped by (name) *
Disposal Site *
Time of Arrival * Time of Departure *
OUTLET SIDE: Thickness of material floating / grease (inches) *
OUTLET SIDE: Solids / food on bottom (inches) *
Method of Measurement *
Sludge Judge Dipstick Estimate Other
Total capacity of interceptor (gallons) *
Total amount pumped (gallons) *
Condition of Grease Interceptor *
Does the baffle have structural problems? * Yes No Missing
Does the inlet have structural problems? * Yes No Missing
Does the outlet have structural problems? * Yes No Missing
Is the interceptor leaking? * Yes No
Does the interceptor show signs of corrosion that would cause it to fail? * Yes No
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