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FOG - Change Form

  1. This is a food establishment certification of 1) No change to facilities or 2) Renovations/Alterations to facilities
  2. It is the responsibility of the food establishment to disclose information on renovations and alterations to the City of Dubuque. Alterations found during inspections not previously submitted to the City of Dubuque will result in a penalty. Please indicate below, any renovations or alterations made in the plumbing, menu, appliances, or any other changes that correlate to the fats, oils, and grease (FOG) program:
  3. As indicated on current permit or hauler manifest. If the permit number is unknown, call 563-589-4176.
  4. Renovations/Alterations
    Please indicate any below:
  5. Establishments that have made any renovations or alterations must fill out a revised permit application and submit this application to the City of Dubuque. Applications can be found at under the Helpful Documents tab.
  6. By checking this box, I certify, under the penalties of law, that the contents of this application to the best of my knowledge including my kitchen fixtures and layout are accurate and complete.*
  7. The permit process is not considered complete until this form AND payment are received.
    Please refer to the invoice for amount due.
  8. Payment methods:
    Mail a check payable to City of Dubuque to:
    Water & Resource Recovery Center
    795 Julien Dubuque Dr.
    Dubuque, IA 52003
    Pay by credit card by calling 563-589-4176
  9. Your permit will be mailed to your establishment once this form and payment are processed.
  10. Leave This Blank:

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