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2. CITY OF MILTON
4. Commercial Wastewater Discharge Permit (CWDP) Application
6. New

   1. yes
7. Renewal

   1. yes
9. Section I. - General Information
11. Establishment Name:*
13. Establishment Physical Address
15. Street*
16. City*
17. Zip Code
19. Billing Address (If different from above) DO NOT USE P.O. BOX
21. Street
22. City
23. Zip Code
25. Telephone Number*
26. Fax Number
28. Website or Email Address
29. Contact Person*
31. Section II. - Facility Operation Characteristics
33. Please choose a description from the list below that best describes the facility:*

    1. Assisted Living Facility
    2. Automotive Repair Garage
    3. Bakery
    4. Coffee Shop
    5. Company/Office Building
    6. Club/Orgianization
    7. Delicatessen
    8. Drive Through (only) Restaurant
    9. Fast Food Restaurant
    10. Food Court
    11. Food Manufacturer
    12. Food Packager
    13. Full Service Restaurant

    1. Gasoline Station w/ Grease Rack
    2. Hospital
    3. Hotel/Motel
    4. Ice Cream Shop
    5. Meat Market
    6. Nursing Home
    7. Religious Institution
    8. School
    9. Seafood Market
    10. Seasonal Restaurant
    11. Vehicle and Equipment Wash
    12. Other________________
35. Please indicate each item currently connected to the City's Wastewater Facility presntly in the establishment:*

    1. 2 Bay/Pre Rinse Sink
    2. 3 Bay Sink
    3. Deep Fryer
    4. Dish Washer
    5. Floor Drain
    6. Garbage Disposal

    1. Grill
    2. Hand Wash/Single Bay Sink
    3. Mop Sink
    4. Oven
    5. Tilt Kettle/Crock Pot
    6. Other ________________
37. Indicate the seating capacity of the establishment, if applicable*
39. Indicate days and hours of operation:*
41. Section III. - Pretreatment Device
43. Indicate the type of pretreatment device(s) currently in operation at the above facility address:*

    1. Indoor/Internal Grease Trap
    2. Outdoor/External Grease Interceptor
    3. Oil/Water Separator
    4. Floor Drains
    5. Other
    6. None of the Above
45. If there are multiple pretreatment devices available, indicate how many:*
47. Please provide the Grease Trap, Grease Interceptor, or Oil/Water Separator specifications below:
49. Internal Dimensions or Total Volume:*
51. Location(s) Inline:*
53. Manufacturer Data (if known):*
55. Model Number(s) (if known):*
57. Are there any additives placed into the plumbing facilities or pretreatment device (i.e., enzymes, bacteria, etc.)?*

    1. yes

    1. no
59. If the answer to the above was in the affirmative, please provide the following information:
61. Upload (if available) the MSDS for the product(s) used
63. Additive Name:
65. Location where added to the system:
67. The frequency at which the additive is applied
69. Section IV. - Renewal Facility Information
71. Have there been any changes, expansions, or modifications to the above establishment's pretreatment device since the issue date of the establishment's last Commercial Wastewater Discharge Permit?

    1. yes

    1. no
73. If the answer to the above question was in the affirmative, please indicate below the extent of the change, expansion, or modification:
75. Have there been any changes, expansions, or modifications to the above establishment's physical characteristics, including but not limited to the kitchen, seating capacity, plumbing, and general strucutre since the issue date of the establishment's last Commercial Wastewater Discharge Permit?:

    1. yes

    1. no
77. If the answer to the above was in the affirmative, please indicate below the extent of the change, expansion, or modification that has occurred:
79. Section V. - Disposal (Applicable to Grease Interceptors and Oil/Water Separators)
81. Provide the name of the contracted Florida Licensed Grease Waste Hauler that collects, removes, and disposes of the fats, oils, and grease material produced at the above establishment:
83. Provide the telephone number of the contracted Florida Licensed Grease Waste Hauler that collects, removes, and disposes of the fats, oils, and grease material produced at the above establishment:
85. Does the above establishment recycle any used fryer/yellow/tallow oil or grease produced on site?*

    1. yes

    1. no
87. If the answer to the above was in the affirmative, please provide the name of the Florida Licensed Grease Waste Hauler which collects, removes, and disposes of the fats, oils, and grease produced at the above establishment:
89. If the answer to the above was in the affirmative, please provide the telephone number of the Florida Licensed Grease Waste Hauler which collects, removes, and disposes of the fats, oils, and grease produced at the above establishment:
91. Section VI. - Authorized Signature
93. I certify the I understand that pursuant to Article V. Division 5. of the Chapter 48, The City of Milton, Fats, Oils, and Grease Management Program, of the CIty of Milton Code of Ordinances, that all food service establishments and automotive related enterprises must have installed a fats, oils, and grease pretreatment/removal device prior to discharging into the CIty's Wastewater Treatment System/Sanitary Sewer System. I further 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 personne 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 is, to the best of my knowledge and belief, true, accurate, and complete. I am aware there are significant penalties for submitting false or misleading information, including but not limited to the possibility of fine and imprisonment.
95. Name/Signature*
96. Title*
98. Date*
99. Phone Number*
101. STOP - BELOW IS FOR CITY USE ONLY
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