HomeMy WebLinkAboutGREASE MANAGEMENT PLAN REVIEWSCANNED
BY
St. Lucie County
PSLUSD Grease Management Plan Review /%:7-
0
. . . . . . . . . .
-ACtry.forAflAp�' Please provide all information requested. Failure to do so will result in an extended review process.
Authorized Representative Information
1. Legal OwnerName:
(i.e. My Restaurant LLC)
Lep] Owner Address: ft!57j P�qtST.LL�� TA- 14 C7 8.3,
Street City State Zip Code
4 (�O GOAVL�
Legal Owner E-Mail Legal Owner Phone
Legal Owner Cell Phone Legal Owner Fax
2. Local Contact Name:
Local Contact Company and Name:
Local Contact Address: 15- �J9 9E F R S
Street City State Zip Code
Local Contact E-Mail Local Contact Phone
Local Contact Cell Phone Local Contact Fax
3. Where do you want future mailings sent? El Facility El Local Contact D-Legal Owner
77ris is thepeison thaiPSLUSD directi), contacts with questions about theplan review and construction and will receive theplan
review comments.
Facility Information
4. Is this 0 new construction or a ant improvement? Is building El free standing or'K!1ocate:din a stri enter?
D
S. Square footage of facility:96w eals per Day. eating Capacity: QLo 0 seats (include) doutdoorseating)
7 —Ak-
6. Current Name of facility: Pho
7. Current Name of plaza/shopping center: �,,j6g Fjo—z:r5 ,
Facility
Street
Mailing address for above (if different than Street
State ZiD Code
Facility Type:
S. Check.Facility Type
(i�u��
Catering business
Medical or lab related
Seasonal restaurant
Foodinanufacturer
Laundry
Fast food restaurant
Nursinghome
Photo development
Drive thin only restaurant
School
Animadhospital/grooming
Coffee shop
Hospital
Retail outlet
Bakery
Hotel/motel
Office building
lee cream shop
Club/organization
Food market
Automotive related
9. Hours of Operation:
M:
11 ue. — 10,40 F:
W-3,o
7:
0. �C, S:
W:
10 --�o S
Th:
0-vo
10. —CookingEguipmenti
No
Ses No
Oven
(:� �Ql
Charhmiler
! 1. XIIIi(:;:
and washing
Vegetable P
12. Employees per shift:
Shift: 4.;t
Shifl: N%j
Ell o
13. Type of dishes upon which food will be served: Washable
Grease Interceptor Information
14. Make and model ol'Gicuse Interceptor:
16. Name ofgeneral colitracLol:
M Name of grease interceptor installer
Page 2 o1*3
S =Ove �)
lhoiler
Other
Describe:
rm�o D
=waslei
I
# Employees V,
# Enipfoye"
11 rmploycn
Disposabic — Both ��
11SLUSI) Doc, �1(, .!:!
installer Address:
Street
ContactName:
1��Nvmbcr:
City State Zip Code
E-mail:
Phone:
Attach Site Plan, Plumbing Plans and PhotogrUbs and any other infor-rnation pertinent 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:
Title: 'n -
Printed Name: kI\CvAE-L Mv,,T-
Date: 6, —2, —1 -5-
'For,Off
iceTsvofily: -
Yroject-Number
oe .-A.grpas'einterceptoris req
Condifi o as 34�5�7 qah-ln"j
(n - L46
IMIA-M
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