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PUBLIC WORKS – UTILITIES DIVISION INDUSTRIAL WASTE PERMIT APPLICATION FOR FOOD SERVICE ESTABLISHMENTS Page 1 of 2 Establishment Information: Name: Site Address: Zip: Phone: ( ) - Email: Contact: Billing Information: Name: Mailing Address: City: ST: Zip: Phone: ( ) - Email: Was space previously occupied? If so, identify previous tenant & type of business: Days/Hours of operation: Sun. Mon. Tues. Wed. Thurs. Fri. Sat. Do you have a grease trap, interceptor, or grease removal device? Yes No Grease trap/interceptor size Location (front/back/side) Will your business have any of the following? (Check Yes or No) Oven Yes No Range Yes No Grill Yes No Fryer Yes No Garbage Disposal/Grinder Yes No Grill hood cleaning Yes No Dishwasher Yes No Disposable dishes/utensils Yes No Washable dishes/utensils Yes No Take-out service Yes No Serving dishes washed on site Yes No Catered by outside vendor Yes No Salad bar Yes No Other (please explain): OFFICE USE ONLY IW Permit Stand 5 Year Change of Ownership ---PAGE BREAK--- Page 2 of 2 How many of the following will your location contain? Vegetable sink(s) Pot sink(s) Mop sink(s) Bar/cocktail lounge sink(s) How would you classify your establishment? Full-Service Yes No Self-Service Yes No Fast Food Yes No Take-out Yes No Donuts Yes No Supermarket Yes No Bakery Yes No Delicatessen Yes No Sandwich Shop Yes No Yogurt/Ice cream Yes No Other (please explain): Please attach a copy of the menu and initial below: I certify that the information submitted about my establishment is accurate. I agree that all food items served are accurately represented in the attached menu. If any change will be made to these food items, I agree to notify the City of Palmdale and abide by any further City of Palmdale requirements as a result of this change. I understand that menu modifications or changes to the kitchen hardware may require the installation of a new or upgraded grease removal device or devices in accordance with the City of Palmdale Plumbing Code to accommodate an increase in grease discharge. I acknowledge that I will comply with any additional City of Palmdale requirements and will inform the city of any change in management, ownership and/or use, including expansion. Print Name Signature Title Property Owner Information: Name: Assessor’s Parcel Identification: Address: