FSE Wastewater Discharge Permit

FOOD SERVICE ESTABLISHMENT (FSE) WASTEWATER DISCHARGE PERMIT APPLICATION

(No fee required for permit issuance) (Questions: Call 864-608-3546)
SECTION A – GENERAL INFORMATION
1. Business Establishment Name
Business Name
Store #
2. Business Establishment Mailing Address
Business Establishment Mailing Address

Street Address or PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Website
Business Email
example@example.com
3. Business Establishment Physical Address (if different from above)
Business Establishment Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. Owner of Business Establishment
Name of Owner of Business Establishment

First NameLast Name
Owner of Business Establishment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Owner Email
example@example.com
5. Name of Owner of Premises (if different from 4 above)
Name of Owner of Premises

First NameLast Name
Owner of Premises Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner of Premises Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Owner of Premises Email
example@example.com
6. Designated Business Establishment Signatory Authority
Name of Signatory Authority
Title of Signatory Authority
Address of Signatory Authority

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signatory Authority Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signatory Authority Email
example@example.com
7. Designated Business Establishment Contact Name
Designated Business Establishment Contact Name
Name
Designated Business Establishment Contact Title
Title
Designated Business Establishment Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Designated Business Establishment Contact Email
example@example.com

SECTION C – WASTEWATER DISCHARGE INFORMATION
1. Please check the item which best describes your wastewater discharge:
Estimated monthly wastewater discharge (gallons)
2. Are there any changes or expansions planned in the next five years that could alter the wastewater volume or characteristics?
Since you answered “Yes” to Question 2, briefly describe the proposed changes and their anticipated effects on wastewater volume and characteristics.

SECTION F – RECYCLING
1. Do or will you recycle the grease produced at your facility?
What is the name of the company that recycles your grease?
If unknown or not yet selected, enter “Unknown.”
2. Is there a recycling container on site?
Number and location of container
3. Have pollution prevention measures (Best Management Practices) been implemented?
Please describe:
4. PLEASE ATTACH A COPY OF YOUR MENU.

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Authorized Representative Certification
Authorized Representative Statement:

I certify that I understand that food service establishments may be required to have a grease removal device before being allowed to discharge wastewater containing fats, oil, and grease to the Greer CPW sewer system. I further certify under penalty of law that this document and all attachments were prepared under my direct supervision in accordance with a system designed to assure that qualified personnel properly 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 that there are significant penalties for submitting false information, including the possibility of fine and/or imprisonment for knowing violations.
Name:
Title:
Date (Today's Date - Read Only)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

FOOD SERVICE ESTABLISHMENT (FSE) WASTEWATER DISCHARGE PERMIT APPLICATION

SECTION A – GENERAL INFORMATION

1. Business Establishment Name

2. Business Establishment Mailing Address

3. Business Establishment Physical Address (if different from above)

4. Owner of Business Establishment

5. Name of Owner of Premises (if different from 4 above)

6. Designated Business Establishment Signatory Authority

7. Designated Business Establishment Contact Name

SECTION B – FACILITY OPERATIONAL CHARACTERISTICS

SECTION C – WASTEWATER DISCHARGE INFORMATION

SECTION D – TREATMENT – GREASE REMOVAL DEVICE (GRD)

Grease Removal Device Information

SECTION F – RECYCLING

Authorized Representative Certification