City of Houston
Houston Health Department
Consumer Health-FOG Program
Main Line: (832) 393-5740
NOTICE OF WAIVER APPLICATION FOR:
REDUCTION TO MINIMUM 180-DAY
INTERCEPTOR CLEANING FREQUENCY
Please fill one application for each TCEQ#
TCEQ #: _________________ Telephone No:_________________________
Company Name: _________________________________________________ E-mail Address: _____________________________________
Interceptor Address: ______________________________City: __________________ Zip:___________
Mailing Address: _________________________________City: __________________ Zip:___________
Generator is responsible for submitting waiver application to the City of Houston Health Department.
Must be in operation and in compliance for a full 12 months and have a 90 day pump out history before waiver will be granted. Please attach
copies of the waste manifest for the last (4) cleanings prior to submitting application and Affidavit of Holding Capacity form.
For the Notice of Waiver to be effective under Chapter 47-512(e), please answer the following:
YES NO
1. □ □ Has your interceptor or holding tank overflowed during the previous 12 month?
2. □ □ Have you received a verbal warning, notice of violation or a citation regarding your interceptor from any governmental entity
(including, but not limited to, City of Houston Health Department) during the previous 12 months?
3. □ □ Is the capacity of your interceptor consistent with uniform plumbing code, as currently adopted by the city?
4. □ □ Will the interceptor produce an effluent consistent with the discharge parameters specified by Chapter 47-514 of Code of
Ordinances with the reduced frequency requested?
5. □ □ Will the interceptor contain more than 25% of floating materials, sediment, oils, or grease at any time based on the reduced
cleaning frequency?
A generator must comply with each element of Chapter 47-512 (e) in order to be exempt from the clean out requirement. The Notice of Waiver does not
relieve the generator from the requirement of having the interceptor fully evacuated, cleaned, inspected, and if needed, repaired or maintained, at least
every 180 days and its waste properly disposed of in accordance with federal, state, and local regulation. Violations of ARTICLE XI.
TRANSPORTATION AND TREATMENT OF CERTAIN WASTES Sec 47-411 through 47-600 will result in the Notice of Waiver being denied or
cancelled. All representations in Notice of Waiver are conditions upon which the generator shall operate its interceptor. The applicant will operate its
interceptor in compliance with the Code of Ordinances of the City of Houston and all applicable laws. The signature below indicates that, based on
information and belief after reasonable inquiry, the statements on this Notice of Waiver are true, accurate and complete.
All sections of this application MUST be complete or application will not be reviewed. E-mailed/Faxed applications will not be accepted.
Please mail completed Notice of Waiver Application, last (4) copies of waste manifest and Affidavit of Holding Capacity to:
City of Houston- FOG Program 7411 Park Place Houston, TX. 77087
In the event you are approved the waiver is only valid for that ownership and TCEQ#.
For Office Use Only
Date Reviewed __________
Reviewing Official _________
NOV ________
Citations _______
Comments: __________________________________________
___________________________________________________
___________________________________________________
_____________________________________
Exemption Granted: □ YES □ NO
TRANSPORTER’S CERTIFICATION FOR QUESTIONS 4
ND 5
BOVE
Transporter Certification: I certify that the frequency (#____Times/Yr) of cleaning at this facility is sufficient to maintain required effluent discharge or
will demonstrate less than 25% of wetted hei
ht of Slud
e Jud
e.
Sec.47-512
e
2
_______________
Transporter Company Rep. (Print Name)
_______________
Signature
__________
Date
Trans
orte
Com
an
’s Name:
COH Permit Number:
GENERATOR’S CERTIFICATION FOR QUESTION # 1, 2 AND 3 ABOVE
_______________________________ _________________________________________ __________________________
Print Name of Generator (Owner Representative) Generator Signature Date
