Facility Information Update Form

3780 South 1550 West St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Facility Information Update Form
Name of Facility *
Facility Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Facility Contact Name *
Facility Contact Email *
example@example.com
Phone Number *

Area Code Phone Number
C. Source Control Present
*Pretreatment Type *

Grease Interceptor Sand/Oil Interceptor Grease Trap No Pretreatment
*If an interceptor is selected above, provide the name of the contracted pumping company.
If the interceptor services more than one facility please provide the following information:
Name of Responsible Party
Mailing Address
Phone Number
Email Address
D. Signatory Requirement
The above information is accurate to the best of my knowledge:
Name *

First Name Last Name
Title *
Signature *

Clear
*Please allow up to 48-hours for review during regular business days, and up to 72-hours if submitting during weekends or holidays.
SGRWRF Pretreatment Department Use Only
Is the facility in compliance with the source control program:

Yes No
Follow-Up action required:

Yes No
If follow-up required, explain:
Inspector:
Date

Month Day Year
Date
Should be Empty:

C. Source Control Present