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WASTEWATER ADDITIVE USE VARIANCE REQUEST FORM <br />CITY OF SANTA ANA <br />Fats, Oils, and Grease (FOG) Control Program <br />City of Santa Ana’s (City) Fats, Oils, and Grease (FOG) Control Regulations, (Article III, Chapter 39, <br />Section 39-56 of the City’s Municipal Code) - prohibits the introduction of additives into a Food Service <br />Establishment’s (FSE) wastewater system for the purpose of emulsifying FOG, for grease remediation, or <br />as a supplement to interceptor maintenance unless specific written authorization from the City’s FOG <br />Control Program Manager is obtained. ANY REQUEST WILL BE DENIED IF THE FSE IS FOUND <br />TO BE, OR HAS BEEN, IN VIOLATION OF ANY FOG PROGRAM REQUIREMENTS WITHIN <br />THE 12 MONTH PERIOD PRIOR TO THE DATE OF THE REQUEST. <br />Food Service Establishment Requesting Variance: <br />Permit No:________________ Rev No: ________ Business License No:_________________ <br />Facility Name:_____________________________________________________________________ <br />Facility Address: ___________________________________________________________________ <br />Owner Name:_______________________ Authorized Agents Name:_________________________ <br />Additive: <br />Product Name: _____________________________________________________________________ <br />Product Description:_________________________________________________________________ <br />Product Key Constituents (attach a copy of the MSDS): _____________________________________ <br />__________________________________________________________________________________ <br />Product Supplier/Distributor Information <br />Company Name: ________________________________________________________ <br />Contact Name:__________________________________________________________ <br />Contact Phone No.: ______________________________________________________ <br />Purpose for additive use: _____________________________________________________________ <br />__________________________________________________________________________________ <br />__________________________________________________________________________________ <br />Justification for Request for Variance: <br />Note – statement must include discussion of product’s potential impact to the City’s sewer system <br />(including potential FOG accumulation and hydrogen sulfide concentrations \[HS\]), potential impact <br />2 <br />to the Orange County Sanitation District’s Wastewater Reclamation Facility, and potential impact to <br />the waters of the State of California. <br />__________________________________________________________________________________ <br />__________________________________________________________________________________ <br />__________________________________________________________________________________ <br />__________________________________________________________________________________ <br />__________________________________________________________________________________ <br />__________________________________________________________________________________ <br />I request a variance for the use of the aforementioned additive and certify that all information contained in <br />this request is true: <br />Signature: ________________________________ Date: ________________________ <br />Printed Name: _____________________________ <br />Submit Variance Request to: FOG Control Program Manager, City of Santa Ana <br /> 220 South Daisy Avenue, Santa Ana, California 92702 <br />Revision Date: April 30, 2007 <br /> <br />