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Business Name*
Business Owner/Agent Name*
Facility Street Address*
Business Owner/Agent Phone Number*
Business Owner/Agent Email Address*
Mailing Address(if different from Facility Address
City
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Point of Contact (POC)*
POC Phone*
POC Email*
Facility Type*
1. Existing Facility
1. New Construction
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Food Service Activity

Facility Exemption Eligibility

The following checklist will help determine if your facility may be eligible to qualify for an exemption. Please mark all activities that apply to your facility:
Level 1
1. The food service facility will sell/serve/provide only prepackaged foods.
2. The food service facility will warm prepackaged foods in their original packages, utilizing a microwave oven.
3. The food service facility will sell/serve/provide only clear drinks. Clear drinks are those which do not include ingredients that ultimately coagulate and/or precipitate from solution
4. The food service facility will only sell/serve/provide ready-to-eat foods, with no preparation other than warming.
5. The food service facility will engage in a limited amount of ware washing, and does not have a3-compartment sink.
Level 2
1. The food service facility will sell/serve/provide cold sandwiches only.
2. The food service facility will sell/serve/provide scoop–only ice cream.
3. The food service facility will sell/serve/provide popcorn.
4. The food service facility will have a hot dog roller.
5. The food service facility will prepare uncooked or unbaked food or meals that will be taken from the facility to be cooked and/or baked elsewhere.
Level 3
The food service facility will use the following kitchen equipment:
1. Wok Stove
2. Oven
3. Food grinder/garbage disposal
4. Deep fryer
5. Dishwasher
6. Griddle
7. Flat top grill
8. Mixer/blender
9. 3-Compartment sink
Level 4
The auto repair shop/car wash facility:
1. has drains connected to the sewer system in areas that equipment maintenance is performed
2. has drains connected to the sewer system in areas that cars or equipment are washed
If you marked Level 1 items ONLY, you may be eligible for grease interceptor exemption.
If you marked Level 1 and/or Level 2 items ONLY, you may be eligible for a grease interceptor variance (i.e. under sink trap or hydromechanical interceptor).
If you marked any of the items in Level 3 or Level 4, you will most likely not be eligible for an exemption or variance. (Some exceptions may apply)
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AGENT/OWNER CERTIFICATION STATEMENT
I certify under penalty of law that this document and all of its attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage that system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment, for knowing violations.
First Name*
Last Name*
Date*
Date
Official Use Only:
1. Grease Interceptor Exemption
2. Grease Interceptor Variance
3. Under Sink Grease Trap Required
4. Under Sink Grease Trap Recommended

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Grease Interceptor Exemption/Variance Request Form

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