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Food Service Facility Quarterly Report

Directions
Include cleaning and maintenance receipts along with the Maintenance Log when submitting. The quarterly reports shall be postmarked, faxed, e-mailed or hand delivered no later than ten (10) business days following the reporting quarter. If you have questions, please call 317-595-3281 or email us at farnhamr@fishers.in.us
End of Reporting Quarter
Today's date
Today's date
Name of person completing this form*
Name of business or facility*
Street address*
City*
State*
Zip*
Phone*
Fax*
Mailing street address*
City*
State*
Zip*
Designated facility owner, registered agent or responsible official
Name*
Title*
Phone*
Fax*
Grease waste hauler (company that hauls interceptor/trap waste)
Name*
Street address*
City*
State*
Zip*
Phone *
Fax*
Grease waste hauler (company that hauls "yellow" grease stored in a container)
Name*
Street address*
City*
State*
Zip*
Phone*
Fax*
Has a modification been granted to your facility?*
1. Yes
2. No
If yes, please explain*

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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