HomeMy WebLinkAbouthood-exemptionRonald Browder, Director of Environmental Health
Phone: 510.567.6700 Fax: 510.337.9135
APPLICATION FOR EXEMPTION FROM MECHANICAL VENTILATION
1.Applicant Name(s): _____________________________________ Telephone: _______________________
Applicant Name(s): _____________________________________ Telephone: _______________________
2.Facility Name: __________________________________________________________________________
Facility Address: ________________________________________________________________________
3.Facility Type: Restaurant Market Bakery Other _________________________
4.Appliance Type (rotisserie, oven , etc.): _______________________________ Weight: __________
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Equipment Manufacturer : ________________________________________________________________
Address: _______________________________________________________________________________
Model: ___________________________________________ Specifications Included? Yes No
Heat Source: Electric (Power Rating ________KW) Gas
Other (specify):_________________________________________________________________________
Certified to meet NSF/ANSI Standard 4? Yes No
If “yes”, certifying organization: NSF Intn’l ETL-Sanitation UL-EPH CSA-Sanitation
Other certifying organization (specify):_____________________________________________________
8.Hours per day of operation of appliance: __________ Number of days/week: __________
9.Approximate size of facility (square feet): ________ Of area/room with cooking equipment: ________
10.Area/Room ceiling height _____________ Ventilation (CFM ) in room/area _____________
11.Number of appliances currently in use that have been previously approved for use without mechanical
ventilation: _____
12.How many appliances are you requesting to install without mechanical exhaust ventilation?: _____________
13.Types of foods to be cooked in the appliance (check all that apply):
a)Pre-cooked wrapped/packaged foods-reheat only:
b)Baked goods: (including bread, rolls, pastries, pies, cookies, cakes, etc.):
c)Vegetables: (including baked potatoes, steamed vegetables, beans, etc.):
d)Pizza: frozen par baked: made fresh:
e)Sandwiches: (containing only ready to eat fillings):
f)Raw meats and/or raw eggs: (meat, fish, poultry):
g)Open cooking: (saute, grill, etc.):
h)Deep fat fried foods:
i)Other (specify) :14."Ductless" ventilation provided: Yes No
If yes, is it included with appliance? or installed separately?
Ductless Hood Manufacturer : _______________________________ Model: ________________________
Complies with UL Standard 197? Yes No
15.If the type of operation changes or the recirculating system or cooking system use causes sanitation, ventilation or
safety issues, this exemption may be revoked and an approved mechanical exhaust system will be installed, or the units
will be removed. Also, if ownership is changed, the new owner/operator will be informed of these operating conditions.
Yes No
APPLICANT SIGNATURE DATE
FOR OFFICE USE ONLY
Recd by________________________ Date ______________________ Amt. Recd ________________________
EPA 202