Pretreatment Service Request

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

IvinsSanta ClaraSt. GeorgeWashingtonOther:Other
Requestor Information:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Department*
Email Address*
example@example.com
Date of Request*

MonthDayYear
Date
Reason for Request:
Dye TestGrease Interceptor InspectionGrease Trap InspectionSand/Oil Interceptor InspectionOther:Other
Request Location Information:
Business Name*
Type of Business *
(i.e. restaurant, automotive, etc.)
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requested date(s) for inspection:

*Please allow 24-hours from the date submitted to the requested inspection date. List your requested times in order of preference.
1st preferred date of inspection*

MonthDayYear
DateHourMinutesAM/PM Option
2nd preferred date of inspection*

MonthDayYear
DateHourMinutesAM/PM Option
3rd preferred date of inspection*

MonthDayYear
DateHourMinutesAM/PM Option
Contact Name*

First NameLast Name
Contact Title*
Phone Number*

Area CodePhone Number
SGRWRF Pretreatment Department Use Only
Is the facility in compliance

YesNo
Follow-Up action required:

YesNo
Findings and/or follow-up action required:
Inspector:
Date

MonthDayYear
Date
Should be Empty: