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NIBBLER Quality Control Questionnaire

Fast Food Restaurant
***Complete all applicable fields***

Incomplete questionnaires will delay your response
Complete this NIBBLER Quality Control Questionnaire
Facility Name:
Facility Owner:
Facility Phone:
Facility Street Address:
Facility City/Town:
Facility State/Province:
Facility Postal Code:
Facility Country:
Company Mailing Information: (Check Box if Same as Company Location)
Facility Mail Address:
Facility Mail City/Town:
Facility Mail State/Province:
Facility Mail Postal Code:
HOURS OF OPERATION:
Peak Season - Enter total hours for each day
Mon Tues Weds Thurs Fri Sat Sun
 
Off Season (If Applicable) - Enter total hours for each day
Mon Tues Weds Thurs Fri Sat Sun
SPECIAL CONSIDERATIONS:
Public Restrooms:
Kid's Play Area: If "Yes" is it enclosed?
Other:
Number Meals Served (check all that apply)
Peak Season Off Season (If Applicable)
Breakfast:   Breakfast:  
Lunch: Lunch:
Dinner: Dinner:
AVERAGE NUMBER OF MEALS SERVED OR TRANSACTIONS PER DAY:
Peak Season - Enter total hours for each day

Indicate Meals or Transactions:
Mon Tues Weds Thurs Fri Sat Sun
 
Off Season (If Applicable) - Enter total hours for each day

Indicate Meals or Transactions:
Mon Tues Weds Thurs Fri Sat Sun
 
Special Occasions (i.e. Mother's Day, Father's Day, etc.) where meals served exceeds Numbers Shown above:
DRIVE-UP WINDOW?:
Peak Season - Enter total hours for each day
Mon Tues Weds Thurs Fri Sat Sun
 
Off Season (If Applicable) - Enter total hours for each day
Mon Tues Weds Thurs Fri Sat Sun
SEATING:  
Total: Indoor: Deck/Patio: Kid's Play Area:
TYPE OF MENU (Check all that apply):
Hamburger:  
Seafood:
BBQ:
Oriental:
Mexican:
Chicken:
Italian:
Breakfast:
Other:
GENERAL (Answer all that apply):
Salad Bar:
type of cooking oils/fat used (check all that apply): Animal:  
  Vegetable:
  Liquid:
  Solid:
Deep fat fryer?:
Ice Cream or
Frozen Yogurt machine?:
Garbage Disposal Used?:
Tableware Type:
Are washable dinner and cookware scrapped into garbage to be disposed of prior to rinsing or washing?:
Dishwasher?:
Does The Dishwasher
Have A Hot Water Rinse?:
Does The Dishwasher
Have A Chemical Rinse?:
Do you have an open
screen installed after
the sink or dishwasher?:
If there is an open screen
for the dishwasher, how
often is it cleaned per day?:
Are any ice machines or other cooling devices plumbed to send waste water to the septic system? If so what type of machine (manufacturer and model):
List all fixtures (including bathrooms) that are
rated as low flow:
What is the water pressure?:
Describe any kitchen practices which may raise or lower the water use or waste strength going into your system such as thawing foods under running water, disposal of mop water, use of drain cleaners, floor strippers, degreasers, hood cleaning products, etc?:
Does the facility utilize
a grease trap inside
the building?:
If there is an internal grease trap how often is it cleaned?:
Flows from the facility are commingled:
Septic Tank(s) total
Capacity (gallons):
Date of last Septic
Tank(s) pump-out?:
How often are Septic
Tanks pumped Out?
Grease Tank(s) total
Capacity (gallons):
Date of last Grease
Tank(s) pump-out?:
How often are Grease
Tanks pumped Out?
MONTHLY WATER METER READINGS (One Year Period)
January:
February:
March:
April:
May:
June:
July:
August:
September:
October:
November:
December:

Please click the "submit" button after you have reviewed your submittal.
Once The NIBBLER Company staff has verified the questionnaire, you will be contacted.

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