Liquid Waste Transporter Company Name:
LW- Pump-out Date:
Required Attachments
1) Pump-out receipt 2) Disposal Facility Ticket
3) FOG Waste Manifest
4) Photos of FCD Location 5) Photos of FCD inside walls 6) Photos of Inlet and Outlet Manholes
Email:
Licensed Plumber License No.:
Name: Phone No.:
Signature: Date:
By signing above, I certify that I performed the assessment and visually inspected the tanks listed below.
Name: GDO No.:
Address:
Tank 1 Tank 2 Tank 3 Tank 4 Tank 5
Yes/No Yes/No Yes/No Yes/No Yes/No
1
2
3
4
5
6
7
8
Outlet (effluent) tee accessible through the outlet manhole?
9
10
Indicate outlet tee's material:
11
Any deficiencies identified above will be verified by the Department and may result in tank replacement.
Facility Owner Name: Signature:
FOR DERM USE ONLY:
For questions about this form, please contact the DERM Water & Wastewater Division at 305-372-6920
Updated: 02/04/2020
Tank Material (Concrete, Fiberglass, Steel, Plastic)
Company Name :
Company Address:
FOG CONTROL PROGRAM - DERM
EXISTING GRAVITY FOG CONTROL DEVICE
(FCD) CONDITION ASSESSMENT
DATE: ____/_____/_________
PUMP-OUT INFORMATION
The contents (Fats, Oils & Grease, Wastewater and Sludge) of the FOG Control Device(s) being assessed shall be completely pumped-
out prior to performing visual inspection
Outlet tee extends to within 8" of the bottom of the tank (h)?
Tank breached or evidence of groundwater infiltration?
Cracks on walls, top or bottom?
Exposed rebar/wire mesh?
Waffling on walls, top or bottom?
Inlet and outlet chambers accessible (manholes provided)?
Watertight manholes?
Outlet (effluent) tee observed?
Professional Engineer
INSPECTION REPORT
Complete checklist below for each FOG Control Device (FCD). Attach additional sheets if > 5 Tanks
Item No.
Item
FOOD SERVICE ESTABLISHMENT / GDO PERMITTED FACILITY
DERM LWT Permit No.:
CONDITION ASSESSMENT CERTIFICATION
The Condition Assessment shall be certified by a Professional Engineer or Licensed Plumber
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PVC
Concrete
Metal
Other ______________________________________________
Page1/2
PLAN VIEW (N.T.S)
L =
W =
H =
SECTION (N.T.S.)
d=
D=
h=
h d=
INCLUDE SITE SKETCH HERE (NTS)
Show building footprint, main streets, and location of the interceptor
TANK2
(
inches)
TANK3
(
inches)
TANK4
(
inches)
EFFECTIVE CAPACITY (gallons)
TANK1
TANK2
TANK3
TANK4
TOTAL CAPACITY (gallons)
TANK1
(
inches)
H
Inlet
Outlet Invert
TANK1
(
inches)
TANK2
(
inches)
TANK3
(
inches)
TANK4
(
inches)
D
L
W
(L X W X H) / 231 in
3
/gal
N
Page2/2
INLET
OUTLET
