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

  1. 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
  2. Part A. Application Information
  3. Part B. Basis for modification request (If further space is required in the completion of this form, attach additional pages)
  4. Part C. Need for modification support documents
    Please attach documentation that will help support your modification request.
  5. Part D. Agreement
  6. 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.*
  7. Leave This Blank:

  8. This field is not part of the form submission.