19F - RECEIVE AND FILE SEWER SYSTEM

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WASTEWATER ADDITIVE USE VARIANCE REQUEST FORM CITY OF SANTA ANA Fats, Oils, and Grease (FOG) Control Program City of Santa Ana's (City) Fats, Oils, and Grease (FOG) Control Regulations, (Article III, Chapter 39, Section 39-56 of the City's Municipal Code) - prohibits the introduction of additives into a Food Service Establishment's (FSE) wastewater system for the purpose of emulsifying FOG, for grease remediation, or as a supplement to interceptor maintenance unless specific written authorization from the City's FOG Control Program Manager is obtained. ANY REQUEST WILL BE DENIED IF THE FSE IS FOUND TO BE, OR HAS BEEN, IN VIOLATION OF ANY FOG PROGRAM REQUIREMENTS WITHIN THE 12 MONTH PERIOD PRIOR TO THE DATE OF THE REQUEST. Food Service Establishment Requesting Variance: Permit No: Rev No: Business License N Facility Name: Facility Address: Owner Name: Additive: Product Name: Authorized Agents Name: Product Description: Product Key Constituents (attach a copy of the MSDS): Product Supplier/Distributor Information Company Name: Contact Name: Contact Phone No.: Purpose for additive use: Justification for Request for Variance: Note — statement must include discussion of product's potential impact to the City's sewer system (including potential FOG accumulation and hydrogen sulfide concentrations [H2S]), potential impact to the Orange County Sanitation District's Wastewater Reclamation Facility, and potential impact to the waters of the State of California. I request a variance for the use of the aforementioned additive and certify that all information contained in this request is true: Signature: Printed Name: Date: Submit Variance Request to: FOG Control Program Manager, City of Santa Ana 220 South Daisy Avenue, Santa Ana, California 92702 19 F -241 Revision Date: April 30, 2007