HomeMy WebLinkAboutGREASE MANAGEMENT PLAN REVIEWPSLUSD Grease Management Plan Review SCANNED
BY
St. Lucie County
fiatkforAftAgee Please provide all information requested. Failure to do so will result in an extended review process.
Authorized Representative Information
L egalOwnerName: C/ AIIVP4�-D 4�/�
01.e. My Rest�t LLQ
Legal Owner Address: Vo�
Street City State Zip Code
,'/ A,5- 9 7-0 D r A 13 6-A -OC,71Z, 41E-,- 7 2 2- 3
Legal Owner E-Mail Legal Owner Phone
772, 39-�Ot/3 3
Legal Owner Cell Phone Legal Owner Fax
,�),ocal Contact Name: C/ Iq 13 Kt? 7'0 D Zc/C,,--F
Local Contact Company and Name:
Local Contact Address:
Local Contact E-Mail Local Contact Phone
Local Contact Cell Phone Local Contact Fax
3. Where do you want future mailings sent? [:3 Facility E3 Local Contact V Legal Owner
This is the person that PSLUSD directly contacts with questions about fhepidn review and construction ondwill receive the plan
review comments.
Facility Information
4. Is this [] new construction or a dtenant improvement9 Is building 10 free standing or elocated in a strip center9
Square footage of facility: ZZi�—ft Meals per Day:'Z 00
6. Current Name of facility:
Seating Capacity: '70 eats (include bar/outdoor seating)
Phone:
7. Current Name of plaza/shopping center: I'/? �Z:�Jq C /? e5? �� 5 I'Al 6;
Facility
I
1 3 �/ Fj— 2--
:1, Z. F /--
city State Zip Code
17 �' *
C� Z. .3
Mailing address for above (if different than Street Address): 0,�; 4 5.
Page lof3
PSLTJSD Doe. No. 22
Facility Type:
8. Check Facility Type:
lvq Full service restaurant
lw�
0 Seasonal restaurant
El Fast food restaurant
r—1 Drive thru only restaurant
E3 coffee shop
E3 Bakery
0 lee cream shop
E3 Food market
9. Hours of Operation:
10. Cooking Equipment:
0 Fryer
29 Grin
-HMN
E::] Wok
El Charbroiler
ii. ainkK
11�3-compartment
[K Hand washing
EA Vegetable
El Catering business
Food manufacturer
Nursing home
School
Hospital
Cj Hotel/motel
El Club/organization
[3 Automotive related
M. 6-3,9 — 9
T: i7o --3
W: 0 — 70
Th: U1, 30 - :2 J�
F:
S:
S: 7—
Stove
Broiler
El Other
Describe:
%Mop
Q� Dishwasher
E] Medical or lab related
E3 Laundry
E—] Photo development
[—I Animal hospitallgrooming
E] Retail outlet
ID Office building
12. Employees per shift:
Shift: 4 Employees
Shift: 4 Employees
Shift: 4 Employees
13. Type of dishes upon which food will be served: Washable Disposable Both
Grease Interceptor Information
14. Make and model of Grease Interceptor:
15. Name of the grease interceptor manufacturer:
16. Name of general contractor:
17. Name of grease interceptor installer'.
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PSLUSD Doe. No. 22
Installer Address:
Street
ContactNarne:
FaxNumber:
E-mail:
State Zip Code
Phone:
Attach Site Plan, Plumbing Plans and Photogaphs and any other information Rertinent or requested by PSLUSD.
The undersigned applicant hereby acknowledges that qualification for the initiation and/or continuation of service is contingent
upon the allowance of random unannounced inspections of the regulated grease interceptor and the grease interceptor
maintenance records required to be maintained on -site by authorized inspectors as required by the City of Port St. Lucie Code
of Ordinances, and hereby consents to such random inspections. The City may deny or revoke a service, impose conditions, or
impose penalties upon evidence that a facility is operating out of compliance with the requirements of the Code.
Signed by Owner/Representative: C--4 -Z
Title: /—/ & f (
PrintedName: UHI.36-A7-cl
Date: 5—z�— A5—
Page 3 of 3
PSLUSD Doc. No. 22