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Food Service Facility Fats, Oils and Grease Program Modification Request Form

Instructions
Submittal of this form does not guarantee a modification will be granted. The grant of a modification based on this form may be revoked at any time if wastewater is identified as having a negative impact to the health, safety, and welfare of others, or if circumstances warrant. A modification only applies to the specific part of the program mentioned in this form and not for any other part. The request will not be processed if it is found to be incomplete. If you have any questions about this form, please call us at 317-595-3281 or email us at farnhamr@fishers.in.us
Part A. Application Information
Date of submittal of application form*
Date of submittal of application form
Date by which modification is needed*
Date by which modification is needed
Name of applicant*
Name of facility*
Address of facility*
Name of owner of the building where the facility is located*
Phone number where the applicant can be reached*
Part B. Basis for modification request (If further space is required in the completion of this form, attach additional pages)
Please specify the part of the Fats, Oils and Grease Program you are requesting the City to modify for your facility*
Please explain the modification you are proposing*
Please explan the reason for this request*
Part C. Need for modification support documents
Please attach documentation that will help support your modification request.
Document 1
Document 2
Document 3
Part D. Agreement
I understanding that the submittal of this form does not guarantee a modification will be granted, and the granting of this modification does not permit non-compliance to any other part of the Fats, Oils and Grease Program. The City of Fishers reserves the right to revoke this modification grant.*
1. I agree
2. I do not agree

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