GREASE INTERCEPTOR CERTIFICATION (Form A)

Every food service establishment in the Metro Nashville Department of Water & Sewerage Services’area must have their grease interceptor

certified annually, as required by their FOG permit, to verify that all components of the grease control equipment are present and in good

working condition. Furthermore, the inspection will identify any structural problems with the grease interceptor.

Facility Name:________________________________________________Phone #:_________________

Address:_____________________________________City:_______________,TN. Zip Code__________

PASS FAIL*

1. Interceptor completely emptied and cleaned before inspection? □ □

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2. There is access to all interceptor chambers for cleaning and inspections? □ □

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3. Influent (inlet) T is attached and extends downward at least 2/3 depth of tank? □ □

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4. Effluent (outlet) T is attached and extends downward to within 12” of tank bottom? □ □

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5. Effluent (outlet) T is made of non-collapsible material that does not easily flex or

bend (i.e. minimum schedule 40 PVC, etc.), and is secure, not allowing fats, oils

or grease to escape around edges? □ □

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6. Interceptor tank does Not have visible holes or leaks? □ □

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7. Mid-wall baffle(s) is secure and operational? □ □

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8. Interceptor maintaining structural integrity? □ □

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9. No Sewer clean-out covers missing or damaged? □ □

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* IMPORTANT REQUIRED INFORMATION & RESPONSE: If the answer to any of the above

questions is “Fail”, the equipment has failed certification. A statement of the plan of action to be

taken, with date to be completed, needs to be provided on the attached sheet under “Response

Comments” (attach additional sheets to explain corrective action if necessary):

Inspector Certification – This grease interceptor has □ PASSED □ FAILED certification.

I ____________________________________of _____________________________________________ (print name of inspector) (print company name)

certify that the above listed facility has an approximate ____________ gallon capacity interceptor. I have

examined the interceptor and provided the above information.

________________________________ ________________ ____________________ (signature) (date) (phone number)

Facility Owner/Manager Certification

I __________________________________ certify to the best of my knowledge the above

(print name)

statements to be true and correct. _________________________________ _______________ (signature) (date)

SUBMIT ORIGINAL CERTIFICATION FORM TO:

Metro Water Services, FOG Control Program, 1360 County Hospital Road, Nashville, TN 37218

This certification form must be completed by a “Metro Certified” Grease Waste Hauler or Plumber.

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Grease Interceptor Diagram

Influent(Inlet) Effluent(Outlet)

RESPONSE COMMENTS (required if “Fail” checked, identify problem, corrective action and

provide planned date of corrective action)