ReWa Food Service Establishment Information Survey

Please provide all information requested and attach plans or building sewer or drain and grease interceptor or trap to this form for review.

* Required Fields

* Facility Name:
* Physical Address:
* City:
* State:
* Zip
* Mailing Address:
* City:
* State:
* Zip
* Name of Owner:
* Daytime Phone Owner:  Area Code: Phone:
* Daytime Phone Facility:  Area Code: Phone:

*Facility Type:
Bakery: Restaurant: Cafeteria: Caterer: Hospital: Nursing Home:
Deli: Butcher Shop: Other:

Seating Capacity:
Beds: (if applicable)
Approximate Water Usage:
Daily: (gpd) Monthly: (gpd)
Tenant Yes   No
New Facility Yes   No
Existing Facility  Yes   No
Renovation/Expansion  Yes   No
Cooking Facilities Yes   No
Existing Grease Interceptor or Trap Yes   No
Capacity of Grease Interceptor or Trap gallons (if applicable)
(For existing facilities, please indicate whether or not there is an existing grease interceptor or
grease trap, provide the capabilities, and indicate whether they will remain in use or be
abandoned or removed.)

 
Does or will this facility generate grease waste? Yes   No
Comments:
* E-Mail:
For more info, call 864-299-4703