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Grease Hauler/Maintainer Registration Form

Note: Fields In Red Are Required

Business Name:

Contact Person First Name:

Contact Person Last Name:

Phone:

Email:

Note: Your login information will be sent to the email address you entered above.

Preferred Contact Method

License:

Business Location

Site Address Line 1:

Site Address Line 2:

Site City:

Site State:

Site Zip Code:

Terms and Electronic Signature Agreement

Terms and Electronic Signature Agreement:

The Grease Waste Hauler/Maintainer understands and agrees that when hired to collect, remove, inspect, dispose, maintain and/or perform any other service to their grease removal systems, that they must be registered to do business in the City of Pembroke Pines and registered with the City’s Food Service Facility (FSF) Online Grease Management Program.

The Grease Waste Hauler/Maintainer understands and agrees to use the City of Pembroke Pines’ FSF Online Record Keeping Program to notify the City of all grease collection, removal, inspections, disposal, and maintenance of grease removal systems located within the City of Pembroke Pines. (There is no charge to register)

The Grease Waste Hauler/Maintainer agrees to keep current any licenses and/or permits that are required by the State of Florida, Broward County and the City of Pembroke Pines to install, collect, remove, inspect, dispose, maintain and/or perform any other service to the grease removal system(s) used in the operation of your Food Service Establishment.

The Grease Waste Hauler/Maintainer understands and agrees to have a representative attend compliance review workshops and to attend subsequent workshops regarding the City's FSF Online Record Keeping Program.

The Grease Waste Hauler/Maintainer agrees that the City’s FSF Online Record Keeping Program administrator may communicate with them electronically for all aspects of their use of the City’s FSF Online Record Keeping Program.

I hereby certify that I have provided true, accurate, and complete information and will maintain and promptly update the registration data to keep it true, accurate, current and complete.

By checking the box and providing my electronic signature, I understand and agree to the Terms stated above and have the authority to electronically sign for the Grease Waste Hauler/Maintainer Business identified above.

I agree.

Printed Name of Applicant

Date