Loading...
HomeMy WebLinkAboutHAZARDOUS WASTE SCREENINGc Mission: SCANNED To protect. promote & improve the health +�- of all people in Florida through integrated BY state, county& community efforts. St. Lucie County HMLTH Vision: To be he Healthiest State in the Nation Fee $10.00(1012012) DATE 1. BUSINESS NAME 2. BUSINESS 3. BUSINESS 4. BUSINESS. S. MAILING ADDRESS 744— HAZARDOUS WASTE SCREENING FOR A LOCAL BUSINESS TAX RECEIPT Location: 3855 S. US Highway 1 Fort Pierce, FL. 34982 6. NAME OF COMMERCIALISHOPPING CENTER 7. PROPERTYIPARCEL PLEASE PRINT Rick Scott Governor Celeste Philip, MD, MPH Surgeon General and Secretary ct_ 8. BRIEF DESCRIPTION OFACTIVITIES �SiAI✓10.WIlj'lR.`yi �IL%1-n L+� t-lC.tyti fl.ybLk%'C'v-' 9. DOES THIS BUSINESS OPERATE AT ANY OTHER LOCATIONS OR BUILDINGS IN THIS COUNTY OTHER THAN AT THE BUSINESS ADDRESS LISTED ABOVE? O Y X N IF SO, WHAT LOCATION 10. IS THIS ANEW BUSINESS? X Y ON � 11. DOES THIS BUSINESS GENERATE OR DISPOSE; PAINT PRODUCTS, SOLVENTS, BATTERIES, CLEANING SOLVENTS, PESTICIDES USED OILS PETROLEUMS, OR OTHER SIMILAR HAZARDOUS WASTE? XY ❑ N PUBLICSEWER: ❑YESANO V` 1rr1`k.� WATERSYSTEM: DPUBLICWATER t og4e(L + �2 ta%CiL SEPTIC TANK: YES ONO » t , - 1 „ UNDERGROUND TANKS: DYES gNO REGISTERED: RYES DNO ❑ WA T rIC.- RESIDENTIAL OFFICE: DYES )(NO DOES BUSINESS CURRENTLY HAVE A LICENSED HAULER:AYES ❑ NO ❑ NIA I HEREBY AGREE THAT THE BUSINESS ABOVE WILL COMPLY WITH ALL FEDERAL, STATEIAND LOCAL H HAZARDOUS WASTE SURVEY REQUIRED: ❑ YES D NO Florida Department of Health -St Lucie County Division of Disease Control and Health Protection Bureau of Environmental Health Location 3855 S US Highwayl, Fort Pierce, FL 34982 Meiling 6150 NW Milner Drive, Port St Lucie, FL 34983 Phone 772-873.4931 Fax 772-595-1306 FloridaHeaith.gov X WELL JUN 16 2017 U i C4.5 WASTE LAWS. Accredited Health Deparbnerit PLUicHeaith Accreditatoi ,86ard INTERAGENCY COORDINATION OF REGULATED ESTABLISHMENTS - DOH/DACS/DBPR/DCF/AHCA/APD EVALUATION OF ONSITE SEWAGE (SEPTIC) AND WATER SUPPLY CAPACITY This evaluation is to ensue: certain regulated facilfties/businesses are evaluated for adequate water and sewage services before opening or expanding operations. If the facility/business is on a DOH regulated onsite well or onsite septic system agency when complete. Section 1- EVALUATION REQUEST FORILICENSING AGENCY ❑ New [tt Expansion / Remodeling ElChange in Occupancy/renancy new buildingor structure (increase in seadng/residents/other) e Licensing Agency: e OBPR CIDACS ❑ DCF ❑ AHCA 13 APO I License Number. C C 62, _ a Contact Perso / Phon . I FAX: / / 2721) Comments: a 8 m eESTABLISHMENTINFORMATION o Establishment Name: h Type of Establishment: Address: �• 5 Fr .E�. Nli'� i�vCt4 Contact Person I Phone#: rr rr 2a .f ) �'r l�G(a.' 0 - L city:re��/ t r L f ( � L.0 u ('✓ �1.. County: { �7i Ltd (l� �.iiul;) Zip: q(� LI`I r Section 2- WATER The atibve named'facil' /business uses the following water -supply choose one a and complete evaluation: ElMunici al/Public Water System Name of Supplier. 7_54afa E S [ c o erg - , n aOnsdeWell:System Permit Number. < Establishment served by a 64E-8, F.A.C., Limited Use Public Water System, DOH Regulated �❑//•' Establishment served by a Florida Safe Water Drinking Act (DEP or DOH) regulated public water system `o SYSTEM EVALUATION RESULT., (ft section below narmaV onfy completed by DOH If an a DOH watersystarrii ly ' ❑ Approved Comments: 0 c 17 Denied 4 0 see comments v Name & Ti tl Printed .YEFj i.4 �—l/ i� r &7//C /��.. County Health Department/DEP/Utility ESignatu Date qJ� ^/7 3 Address EitJ� r1 e)37S.ZIS1, 4Uele..%'L Phone -7 l°�EJ:- - 2--a7$- Section 3 -WASTEWATER, .` Tf9e above nametl foal !business uses the followin wastewater disposal system choose one , and com late evaluation^=`d ❑ Municipal/Public Sewer Name of Supplier. V I Septic System (ons-do wastewater) Permit Number. ) a `3YSTEM.EVALUATION '.RESULT: (this secOnbelow nor O oaf ce letedb DOH If on a septic system) '0 Approved ❑ Single -Service Utensils Only ❑ Number of Residents/Students ❑ Number of Seats Permitted ❑ Number of Beds/Clients I w❑Dented ❑Hours of Operation ❑ Other Conditions (see comments) o - (see comments) ❑ Food Service Yes F No Comments: x 0 0 Name & Title Panted yA r �e��Pe e. G✓ i �. County Health Deparlment/DOH/Utility Signs Date17 Address /� r6137 S. LtS� P4-r-Jf phone 7zz-b'73•-&-0.rr M FAv Cepartmen7dHea0lvaureau glOnaEe Sewage Pro S-Marr 2012 Mission: To protect promote & Improve the health of all people in Florida through integrated state, county & community efforts. Vision: To be the Healthiest State in the Nation Fee $10.00 (1012012) HAZARDOUS WASTE SCREENING FOR A LOCAL BUSINESS TAX RECEIPT DATE Location: 3855 S. US Highway 1 Fort Pierce, FL. 34982 1. BUSINESS 2. BUSINESS 3. BUSINESS 4. BUSINESS NAME I "I. V . i PLEASE PRINT 5. MAILING ADDRESS 6. NAME OF GOMMERCIAUSHO`P�PIING `C1ENTER 7. PROPERTY/PARCEL ID 0 (:!N I �1 r C Rick Scott Govemoi Celeste Philip, MD, MPH Surgeon General and Seaetap CL 8, BRIEF DESCRIPTION OF ACTIVITIES 'ZIUh L0I QLtks i �' fl.QX,ON GQ: P C, / (�1 C KCy-' 9. DOES THIS BUSINESS OPERATE AT ANY OTHER LOCATIONS OR BUILDINGS IN THIS COUNTY OTHER THAN AT THE BUSINESS ADDRESS LISTED ABOVE? ❑ Y X N IF SO, WHAT LOCATION to. IS THIS A NEW BUSINESS? X Y 0 N ,. 11. DOES THIS BUSINESS GENERATE OR DISPOSE; PAINT PRODUCTS, SOLVENTS, BATTERIES, CLEANING SOLVENTS, PESTICIDES USED OILS PETROLEUMS, OR OTHER SIMILAR HAZARDOUS WASTE? XY ❑ N PUBLIC SEWER: ❑ YES ,ENO ram% t I I"t'rC.(.T WATER SYSTEM: 0 PUBLIC WATER �tJ0je(L k Pq tx e•2 SEPTIC TANK: YES ONO N-S _ t ^ UNDERGROUND TANKS: DYES q(NO REGISTERED: RYES ❑ NO 0 N/A -lC r�C• RESIDENTIAL OFFICE: 0 YES NO DOES BUSINESS CURRENTLY HAVE A LICENSED HAULER:,KYES ❑ NO ❑ N/A I HEREBY AGREE THAT THE BUSINESS ABOVE WILL COMPLY WITH ALL FEDERAL, STATE/AND LOCAL H) HAZARDOUS WASTE SURVEY REQUIRED: ❑ YES ❑ NO =Florida Department of Health -St Lucie County Division of Disease Control and Health Protection Bureau of Environmental Health Location 3855 S US Hlghwayl, Fort Pierce, FL 34982 Melling 6160 NW Milner Drive, Port St Lucie, FL 34983 Phone 772-873.4931 Fax 772-595-1306 FloridaHealth.gov A WELL JUN 1 6 2017 WASTE LAWS. ®Accredited Heakh Department . PutilicHeafthAccredit d6nBoard INTERAGENCY COORDINATION OF REGULATED ESTABLISHMENTS - DOHIDACSIDBPRIDCFIAHCAIAPO EVALUATION OF ONSITE SEWAGE (SEPTIC) AND WATER SUPPLY CAPACITY This evaluation is to ensure certain regulated faciktieslbusinesses are evaluated for adequate water and sewage services before opening or expanding operations. If the facilitvibusineso is on a DOH regulated onsite well or onsite septic system, r mnlatinn of this. aualuanpn will facilitate and expedite the soorovel orocess. Please return to the appropriate licensing agenov Section 1 -EVALUATION REQUEST FOWLICENSINGAGENCY T' ❑ New 10 Expansion I Remodeling 113 Change in Occupancyfrenancy new bulldin or structure (increase in seatingtresidentstother) 1! Ucensing Agency: License Number. _ C C 76.Z 3 S DBPR ❑ DACS ❑ DCF ❑ AHCA ❑ APD o Contact Perso ` Pho I FAX < I Q / /27 ,a Comments: a ..:ESTABLISHMENT INFORMATION Establishment Name: h x" I" � A � ' F ` Type of Establishmertt:�-"e `� rtts-k`V `U t t era Address: 5. t 41�c ttaGt Contact P rson I Phone#: Qn f 7npraimiG�l( L City: Pc.k psi Luue �L County., Zip: -^ . Sectt6o�2=WATER She eticvvairatned WIt /busihess mass the foilowi waters I choose one type), and complete evaluation ... ❑ Municipal/Public Water S stem Name of Supplier. i "A,G E S `stem' � § Onsife Well Permit Number. - 3 . - [3 Establishment served by a 64E-9, FAC., Limited Use Public Water System, DOH Regulated ;. Establishment served by a Florida Safe Water Drinking Act (DEP or DOH) regulated pub6Fwater system SYSTEM -EVALUATION RESULT. 013section below completed b DOHMonaDOHwaters c Comments: Approved 0 ❑ Denied sea comments Name & Till E'A " J. &Ai l a A&/e County Health DeparlmenttDEPIUblity (Printed)�t 6 Signatu Date pJ� 20 Address• lEil!© r/ P9.3 7 S. 64S Ao?t J{- &"-;e �C Phone 2— �7 `Section 3--WASTEWATE$, 'tlte•atiova named facil ltiusinesS uses the foilgwin Wastewater disposal m choose one and win rate evaivatimiz> * . a ❑ MunicipaVPublic Sewer Nam; of Supplier. V I Septiesystem(onsitsmstewater) I Permit Number, i a SYSTEMiEVALUATION RESULT: is seetton below no oN coin letedb DOH iron a se ticsystem) . •t] Apprbved` 0 Single -Service Utensils Only O Number of Residents/Students ❑ Number of Seats Permitted ❑ Number of Beds/Crrents t _6a �-❑ Dented ❑ Hours of Operation ❑ Other Conditions (see comments) (see comments) ❑ Food Service Yes E= No Comments: x 0 0 Name & rite County Health Department/DOHIUttlity Printed C a 0 Signs Date^� r ,tea 9-737s L(S':�( PcFX:V tut C AL- Phone -71z2'_s'��-�v�� Fbdl O pa4~10f baff &e u of 0mde Sat Pmanv- At" 2012 A` Rick Scott sslon: Governor To protect, promote & improve the health of all people in Florida through integrated state, county community efforts. __s_v_`:�. Celeste Philip, andMD, MPH HCCGlAA1��L Surgeon Generalral and Secretary Vision: To be the Healthiest State in the Nation Fee $10.00 (101201z) HAZARDOUS WASTE SCREENING FOR A LOCAL BUSINESS TAX RECEIPT Location: 3855 S. US Highway 1 Fort Pierce, FL. 34982 DATE M• 1 f D / ��� PLEASE PRINT 1. BUSINESS NAME C�,V' r l� 1 2. BUSINESS OWNER(S) er U;I1 Oil/ LL� 3. BUSINESS PHONE l(9I+- �� U" 'YA4 ' I _ 1 (� Syr, 4. BUSINESSADDRESS V 5+ 5 �-1 HWL A Low, [�L � q5 A, L / � �(CITY) I 1 (STATE) ?(ZIP))) G 5. MAILING ADDRESS T�L� .Ml L�Y.A 1(.t �� AVA POUF ST LuGR- `L JR-ISS frlT IRTCTFI OIPI 6. NAME OF COMMERCIAL 7. PROPERTY/PARCEL ID 8. BRIEF DESCRIPTION OF ACTIVITIES QWlAUJ l OUt V �OnCk CRJ[e.� r lam' 1+Lh2 Oh '(%� ..� U ICR.S 9. DOES THIS BUSINESS OPERATE AT ANY OTHER LOCATIONS OR BUILDINGS IN THIS COUNTY OTHER THAN AT THE BUSINESS ADDRESS LISTED ABOVE? ❑ Y X N IF SO, WHAT LOCATION 10. IS THIS A NEW BUSINESS? XI Y D N 11. DOES THIS BUSINESS GENERATE OR DISPOSE; PAINT PRODUCTS, SOLVENTS, BATTERIES, CLEANING SOLVENTS, PESTICIDES USED OILS PETROLEUMS, OR OTHER SIMILAR HAZARDOUS WASTE? XY ❑ N PLEASE CHECK THE FOLLOWING THAT APPLY TO� THIS BUSINESS: (MUST BE COMPLETED FOR APPROVAL) PUBLIC SEWER: ❑YES o8NO Mt'n'C(T WATER SYSTEM: ❑ PUBLIC WATER A WELL QCk:kxL + 4 u)eQ- SEPTIC TANK: YES ONO pl1 _U » 1 S UNDERGROUND TANKS: DYES �NO REGISTERED: RYES ❑ NO ❑ N/A T RESIDENTIAL OFFICE: ❑ YES )(NO DOES BUSINESS CURRENTLY HAVE A LICENSED HAULER:,KYES ❑ NO ❑ NIA I HEREBY AGREE THAT THE BUSINESS ABOVE WILL COMPLY WITH ALL FEDERAL, STATEIAND LOCAL HAZARbOUS WASTE LAWS. HAZARDOUS WASTE SURVEY REQUIRED: ❑ YES ❑ NO Florida Department of Health -St. Lucie County Division of Disease Control and Health Protection Bureau of Environmental Health Location 3855 S US Highwayl, Fort Pierce, FL 34982 Mailing 5150 NW Milner Drive, Port St Lucre, FL 34983 Phone 772-873-4931 Fax 772-595-1306 FlorldaHealth.gov ppR-Hi:V UED JUN 1 6 2017 Accredited Health Uepartineni = Pib1I0He6fl)iAccreditatiohftard INTERAGENCY COORDINATION OF REGULATED ESTABLISHMENTS - DOH/DACS/DBPRIDCFIAHCA/APD EVALUATION OF ONSITE SEWAGE (SEPTIC) AND WATER SUPPLY CAPACITY are before agency sewage ' Section 1 - EVALUATION REQUEST FORILICENSING AGENCY 4� O New tit Expansion I Remodeling E Change in Occupancyrrenancy new building or structure (increase in seating/residentslother) V 3 Licensing Agency., e DBPR ❑ DACS O DCF O AHCA O APD License Number. _ C C J2562,05 Contact Perso ' 1 / % Phon . I FAX: c ,a Comments: a m ESTABLISHMENT INFORMATION Establishment Name: {j a 1r � f < l Type of Establishment T p coT r � U� l9 Address: s G! 4 i Cg�tact P rson / Phone#: �. l}O " J Cft -C i1: i ctj IC.t1 :i r 1 4 t� +1, City: PO4 4 L U C: S, R, `)3 5e _ f County: f $ LQJ (( cz. .V; zip Section 2 = WATER , - The=ebovemamedfacilityftsiness usees the following water supply choose one type), and complete evaluahom ❑ Munici al/Public Water System I Name of Supplier. i t—L46 E S t1+-.eL. . n § OnsiteWellSvstem I Permit Number.. }, '- ❑/. Establishment served bya 6468; F.A,C., Limited Use Publie Water System, DOH Regulated Establishment served by a Florida. Safe Water Drinking Act (DEP or DOH) regulated public water system `o -SYSTEM. EVALUATION RESULT: this sect on belowno o com feted b DOH Hon a DOH water a 73Approved Comments: ❑ Denied o(see comments $Named Till -"' fir) P-oPEit printed County Health Deparkrtent/0EP1Utility Signatu Date cJ� 20 f7 8 Address • �18 - n/ 937S.&SY.A-,&J-c_t`_tclre.12 Phone -772-- d' Sectiisn 3 - WASTEWATER " , w:. i�te,e6o le'namad fast "IbusinessYusesthe fogawin .wastewater`dis disposal s tem choose one and com lefa evalua6an. ❑ Municipal/Public Sewer Name of Supplier. V I 44OCZE S4UP_X_'__ (� Septic;System (onslte Wastewater) I Permit Number: ) , ' a SYSTEM EVALUATIONRESULT., (this sectlonbelow namal on w letedb DOHllonase s m a P Ap rdved D Single -Service Utensils Only ❑ Number of Residents/Students D Number of Seats Permitted 0 ❑ Number of Beds/Clients I wi 3 Denied ❑ Hours of Operation 0 ❑ Other Conditions (see comments) o - --(see comments) ❑ Food Service Yes No x Comments: a 0 Name & Title Prtnted iA FAD County Health DepartmentlDOHlUdlity k` 8 Sign Date '7F2D &Ln e A--;va &73 - S. QS-� P 47-S4 4— Phone Fbma Ov15a4-10H-MWHW Grenade SMs Piu®emg-Mm 2012