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2. This form is to be completed by the owner or person responsible for the grease or sand trap at this facility. This form will help you meet the reporting requirements found in Lyons Municipal Code 13-4-160 (b). If you have any questions about the required information, please contact building@townoflyons.com

4. Quarterly Reporting Due Dates
6. Quarter 1 - April 10
   (January-March)
7. Quarter 2 -July 10
   (April-June)
8. Quarter 3 - October 10
   (July-September)
9. Quarter 4 - January 10
   (October-December)
11. Facility Name:*
12. Reporting Quarter*
    -- Select One --Q1 Q2Q3Q4
14. Contact Name:*
16. Business Address*
18. City*
19. State*
20. Zip Code*
24. Option 1.
    If you are currently utilizing a contracted grease waste hauler and they provide you with a Colorado Department of Public Health and Environment (CDPHE) WG-2 Form, you may upload the form here, in leiu of completing this form.
26. Option 2.
    If your business does not contract a grease waste hauler, please fill-in the following fields. If you do not use a contracted grease waste hauler, the Town may require additional inspections.
28. Facility Type:
    -- Select One --Food Service FacilityTransportation FacilityOther
29. Date Report Created
31. Describe Trap Location:
33. Cleaning Performed By:

    1. Contractor
    2. Responsible Party
34. If cleaning performed by Contractor, list Name and License #, if by responsible party, list Name and Title.
    Please submit the CDPHE WG-2 Form from your contractor.
38. Monthly Cleaning Activity Reporting
    Specify Month, Date of Cleaning & Amount of material pumped/cleaned out of trap:
40. Month (1)
42. Month (2)
44. Month (3)
48. Name of Responsible Party
49. Title
50. Date
52. By checking this box...

    1. I certify the above information is correct to the best of my knowledge and understand that I must make available all supporting documentation for these described activities at Town of Lyons request
Leave This Blank:


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

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field