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Please submit application to: City of Modesto Water Quality Control Facility Environmental Compliance Section 1221 Sutter Avenue Modesto, CA 95351 (209) 577-6200 (209) 577-6290 fax Have you initiated a project through Building Safety? ☐Yes ☐No If yes, date plans submitted: Name of assigned plan checker? If no, date this will be initiated: **this application cannot be processed without plans** Please note: submitted plans must contain the facility plumbing diagrams indicating the location of all facility sewer connections, grease removal devices, sinks, floor drains, dishwashers, restrooms, etc. Have you spoken to an Environmental Compliance Inspector regarding this facility? ☐Yes ☐No If yes, who did you speak to? Please fill out application completely. Incomplete applications will not be considered. If you have any questions or concerns, please contact the Environmental Compliance Section. Please choose one description that best describes your facility (check one): ☐ New Food Service Establishment ☐ Modification to Existing Food Service Establishment ☐ Change of ownership Facility Information: 1. Facility Name 2. Facility Street Address 3. Facility Mailing 4. Designated Facility Contact Phone 5. Company/Owner Contact Phone 6. Property Owner (if different than facility owner contact) Phone City of Modesto – Utilities Department Environmental Compliance Section Wastewater Discharge Survey Form / Grease Interceptor Waiver Request Application ---PAGE BREAK--- Facility Operational Characteristics: 1. Choose one description that best describes your facility (check one): ☐ Fast Food Restaurant ☐ Full Service Restaurant ☐ Nursing Home ☐ Drive through (only) ☐ Concession Stand ☐ Hotel/Motel ☐ Coffee Shop ☐ Bakery ☐ Supermarket ☐ Religious Institution ☐ School/College ☐ Club/Orginization ☐ Company/Office Building ☐ Ice Cream Shop ☐ Hospital ☐ Caterer ☐ Convenience Store ☐ Bar/Lounge ☐ Meat Market ☐ Produce Market ☐ Cafeteria ☐ Other 2. Describe the type of food served (attach copy of menu): 3. Indicate each item that is currently installed or will be installed and the quantity of each: ☐ Grill ☐ Oven ☐ Dishwasher ☐ Pre-rinse/spray sink ☐ Mop sink ☐ Deep fryer ☐ Floor drains ☐ Tilt kettle/crock pot ☐ Hand Sink ☐ Three bay sink ☐ Two bay sink ☐ Single bay sink ☐ Garbage disposal ☐ Chinese Wok/cooker ☐ Other 4. Service Method (check applicable): ☐ Washable plates ☐ Disposable plates/baskets ☐ Carry-out 5. Seating capacity of this facility: 6. Estimated average meals per day: 7. Complete the hours of operation for each day that your facility will be open: Tuesday__________ Wednesday__________ Thursday__________ Saturday Existing Fats, Oils, Grease (FOG) Treatment: 1. Is there currently a grease removal device at this facility? ☐Yes ☐No 2. If yes, complete the following and attach manufacturer’s specifications for all devices: a. Make and Model Capacity (gal) or (lbs.) ☐ Passive or ☐ Automatic (check one) ☐ Indoor or ☐ Outdoor (check one) Cleaning frequency Location (under 3-bay sink, in basement, outside in ground, etc.) ---PAGE BREAK--- b. Make and Model Capacity (gal) or (lbs.) ☐ Passive or ☐ Automatic (Check one) ☐ Indoor or ☐ Outdoor (Check one) Cleaning frequency Location (under 3-bay sink, in basement, outside in ground, etc.) 3. If the INDOOR grease removal device (trap) is being maintained onsite, how do you dispose of the waste after cleaning the device (circle one)? ☐ Trash ☐ Contractor disposes of grease ☐ Recycle ☐ Other 4. If a contractor(s) cleans the INDOOR or OUTDOOR grease removal device(s), please list the following: a. Contractor Name Address Phone Number b. Contractor Name Address Phone Number If requesting a waiver from the City of Modesto Grease Interceptor Requirement, please complete the following section: 1. Are you requesting to install/use a grease trap instead of a grease interceptor? ☐Yes ☐No If yes, what capacity? ☐ pre-existing or ☐ new install (check one) or Are you requesting to install/use an outdoor grease interceptor smaller than the minimum size required by the Modesto Municipal Code? ☐Yes ☐No If yes, what capacity? gal. or Are you requesting to forgo all types of grease removal devices? ☐Yes ☐No 2. The justification for this request is based on: Additional Information: ---PAGE BREAK--- Authorized Representative Statement: I hereby certify that the above information is accurate. I acknowledge that changes in cooking methods, volumes and hours of operations will require re-application and possible increase in the size or type of grease removal device. I certify the grease trap will be cleaned in accordance with manufacturer specifications a minimum of once per week or more frequently, if necessary and at least once every three months for outdoor grease interceptors or more frequently, if necessary. I certify that all staff will use best management practices as pertaining to disposal and handling of fats, oils, and grease (FOG). I acknowledge that the required cleaning frequency can be modified at any time by the City of Modesto Environmental Compliance Section. In addition, I understand that, if this application is approved, I will be required to do the following: 1. Establish a routine cleaning schedule of the grease trap or interceptor. 2. Maintain a log of grease trap cleaning and/or copies of grease interceptor pumping and maintenance, to be kept on site for at least three years and made available for inspection and/or copies furnished upon request by the City of Modesto Environmental Compliance Section. 3. Train employees on best management practices to prevent fats, oils, and grease from entering the City of Modesto sanitary sewer system. Furthermore, I understand that, if this waiver is approved to install a grease trap, a solids interceptor shall be installed prior to the grease trap (MMC 5-6.317(b)). I understand that additional equipment and maintenance steps may be required if: 1. The information and plans, as submitted, are changed. 2. The use of the site is changed. 3. The grease trap/interceptor is not maintained as agreed to. In the event that an inspection indicates that FOG has been discharged into the City of Modesto sanitary sewer system from this facility, I understand that the City may revoke this conditional waiver and require a larger grease removal device to be installed at the owner’s expense. Signature Date Printed Title