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1 CITY OF FONTANA DEPARTMENT OF PUBLIC WORKS 16489 ORANGE WAY FONTANA, CALIFORNIA 92335 INDUSTRIAL WASTEWATER PERMIT APPLICATION (SHORT FORM – FOOD SERVICE ESTABLISHMENT) 1. FILING STATUS (Check One) A. New or Unpermitted Construction B. Existing, or Remodeled Facility C. New Ownership Previous Company: Previous Permit Number: D. If other, Please Explain 2. COMPANY INFORMATION A. City of Fontana Business License Certificate No. B. Legal Business Name: Ownership Type: Corporation Partnership Sole Proprietor LLC C. Company Doing Business As (dba): D. Business Officers Names and Titles Proprietors/Partners/Corporate Officers Title or Position E. Facility Location: Address : (Street) (City) (Zip) Facility Contact Person: Phone:(____) Title: email: F. Mailing Address: Name: Address: (Street) (City) (State) (Zip) G. Landlord/Property Owner/Management Company: Property Manager/Owner Name: Address: (Street) (City) (State) (Zip) Attention Name: Phone: email: FOR OFFICE USE ONLY APPLICATION # PERMIT # ---PAGE BREAK--- 2 3. FOOD SERVICE ESTABLISHMENT DESCRIPTION A. Describe Type of Business and Food Served (i.e. fast food, Chinese, Mexican, Family Style, etc.); (A proposed menu must be provided with the application.) B. Date operation began/or will begin? (mm/dd/yyyy) C. Number of Employees: Number of Shifts: D. Hours of Operation: am/pm to am/pm Days Per Week: S M T W Th F S (Circle All Applicable Days) E. Seating Capacity: Total Number of Meals Served per Day: F. Percentage of Meals Served With Washable Tableware: G. Percentage of Meals Served With Disposable Tableware: 4. EQUIPMENT A. Number of Dishwashers: B. Number of Garbage Grinders: C. Number of Deep Fryers: Interior Tank Dimensions: Length Width Depth D. Number of Hot Grills: Give Surface Area Dimensions: Length Width E. Broilers: Yes No Rotisseries: Yes No Microwaves: Yes No 5. GREASE DISPOSAL EQUIPMENT A Grease Interceptor with a sample box is a device that is placed in the ground outside of the building. A Grease Interceptor has two chambers, and typically has a 750 gallon capacity or larger. The device separates and collects oil, grease and solids from the kitchen wastewater and discharges the clarified water to the City’s sewer system. Fontana Municipal Code Chapter 23 Section 23-163, requires all Food Processing Facilities to have an interceptor with a minimum fluid capacity of 750 gallons. Conditional Waivers for the grease interceptor requirement may be granted in accordance with section 23-52. A Grease Trap is a device that is installed in the facility’s kitchen for the purpose of holding waste grease in the wastewater. A Grease/Oil Rendering Service is a service provided by a company to pick up and recycle fats, oils and greases that are usually stored in a rendering barrel provided by the rendering company. A. Grease Interceptor with Sample Box: Yes No If yes, what size? Grease Trap: Yes No If yes, what size? B. Interceptor Service Information Provide Name and Address of Pumping Service: C. How Often Is Grease Interceptor Pumped or Grease Trap Cleaned, daily, semiannually, or annually): D. Grease Rendering Information (Used Cooking Oil) Provide Name and Address of Grease/Oil Rendering Service: ---PAGE BREAK--- 3 6. FRESH WATER TREATMENT The City of Fontana prohibits water softeners that are regenerated on site in excess of one cubic foot. (See FMC Section 23-162). Ion Exchange water softeners that are regenerated off site by a vendor (with no waste discharged to the sewer) are acceptable with a letter of approval for the installation or operation of the device. A. Water Softener: Yes No Regenerative: Yes No Size of Resin Recovery Bed: B. If Regenerated off site, Give Vendor’s Name & Address: 7. AUTHORIZED REPRESENTATIVE STATEMENT I certify under penalty of law that I have personally examined and am familiar with the information in this application form and all attachments and that, based on my inquiry of the persons immediately responsible for obtaining the information contained in the application, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and/or imprisonment. NAME – AUTHORIZED REPRESENTATIVE SIGNATURE OFFICIAL TITLE DATE