Pretreatment Service Request

3780 South 1550 West St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Pretreatment Service Request
Date

Month Day Year
Date
Requesting Agency

Ivins Santa Clara St. George Washington Business Other
Request Location Information:
Business Name *
Type of Business *
Business Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date & Time Service(s) are being requested *

Month Day Year
Date Hour Minutes AM/PM Option
Contact Name *

First Name Last Name
Contact Title *
Phone Number *

Area Code Phone Number
Contact Email Address *
example@example.com
Requestor Information:
Name *

First Name Last Name
Requestor Title *
Phone Number *

Area Code Phone Number
Requestor Email Address *
example@example.com
Reason for Request

Dye Test Grease Interceptor Inspection Grease Trap Inspection Sand/Oil Interceptor Inspection Other
SGRWRF Pretreatment Department Use Only
Is the facility in compliance:

Yes No
Follow-Up action required:

Yes No
Findings and/or follow-up action required:
Inspector:
Date

Month Day Year
Date
Should be Empty:

Request Location Information: