Single-use plastics Waiver Application -Welcome to the City of Pinole

Business Information

Legal Business Name(Required)

DBA (if different)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Type of Business

If other, please enter type of business

Waiver Request Details

Type of Waiver Requested(Required)

Foodware item(s)

Bag(s)

Item(s) requesting waiver for (use the plus symbol to add more items)(Required)

Item

Material

Reason (cost, performance, unavailable, health and safety, other)

Compliance Plan

1. Steps already taken(Required)

2. Planned future actions(Required)

3. Timeline for implementation(Required)

4. Barriers to compliance(Required)

Document Checklist

Upload any applicable/supporting documentation ( □ Correspondence with vendors seeking compliant items □ Vendor responses with specifications and pricing □ Specifications and pricing for non-compliant items demonstrating superiority and/or affordability □ Financial records demonstrating hardship □ Evidence of good-faith efforts to comply □ Health/safety documentation (if applicable) □ Other supporting documentation)

File

Drop files here or

Max. file size: 100 MB.

Certification

Name of Owner/Authorized Representative(Required)

First Last

Title(Required)

Signature(Required)

I certify under penalty of perjury that the information provided in this application is true and correct to the best of my knowledge. I understand that: The foodware item(s) and/or bag(s) waiver, if granted, is valid for up to two years I must continue making efforts to achieve compliance during the waiver period; The waiver will automatically expire if the business undergoes renovation exceeding $60,000 or ceases operations; It is my responsibility to apply for renewal before the waiver expires

Date(Required)