HomeMy WebLinkAbouthood-exemption-application-adaRonald Browder
Director
APPLICATION FOR EXEMPTION FROM MECHANICAL VENTILATION
1.Applicant Name(s):Telephone:
Applicant Name(s): Telephone:
2.Facility Name:
Fcility Address:
3.Facility Type:Restaurant Market Bakery Other
4.Appliance Type (rotisserie oven, etc.):Weight:
5.Equipment Manufacturer:_
Address:
Model:Specifications Included? Yes No
6.Heat Source: Electric (Power Rating KW) Gas
Other (specify):
7.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.Size of facility (square feet): Size 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 ventilation?
13.Types of foods to be cooked in the appliance (check all that apply):
Pre-cooked wrapped/packaged foods - reheat only
Baked goods: (including bread, rolls, pastries, pies, cookies, cakes, etc.)
Vegetables: (including baked potatoes, steamed vegetables, beans, etc.)
Pizza: (frozen, partially baked, made fresh)
Sandwiches: (containing only ready to eat fillings)
Raw meats and/or raw eggs: (meat, fish, poultry)
Open cooking: (saute, grill, etc.)
Deep fat fried foods
Other (specify):
Ronald Browder
Director
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 EPA 202
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
Received by: Date:
Amount Received: Approved: Yes No
1131 Harbor Bay Parkway, Alameda, CA 94502 | Health.countyCA.gov/ACEHD | (510) 567-6700