01-0386-004 CREASE DISCHARGE
RM
OPERATIN&PERMIT
L4)E- , .
APPLICATION
DEPARTMENT OF ENVIRONMF_NTAL RESOURCES MANAGEMENT
33 SW 2nd A»enue, Miami Florida 33130-1540] GDO: 7_71
Project Name: < 3, A� a (24-7L-6
Location: S_;Z 618 �E7—y/7 150U-t# H/-41-7i _ Bay/Unit: _� Zip Code: 3 3�y3
Permittee Name: (?C—,5A6Z. /xi C*OA) Title: 10 FX)T
Company Name: �� �/�d7 C1���EGZv> ga ti--l ,4W �/-i',�E U.`; A-. --
Business Mailing Address: 5/00 JJVJ )Ito CT Telephone: 305�6 9-7-0-2 2-2
City: �A I M I State---'rL Zip Code: 3 3
Folio Number: D 9 CJ O 3 G (DJ;Z O O a3-0 C/O Process #: Affidavit (Y/N):
GENERAL INFORMATION
*Plans are required for New Construction or Interior Remodeling Projects
*New Construction (Check): Expected Date of Completion: COG _ - 05-- 2_0,'
# of Grease Interceptor(s): Size(s): (gallons);-#of Seats:
Automatic Grease Recovery Unit (Check) Model = Capacity: (GPM)
-PAYMENT AFFIDAVIT
Please attach a check in the amount of$900.00 made payable to "Miami Dade County." This fee-amount is basad on
the fee schedule approved by the Board of County Commissioners.
The undersigned owner or authorized representative of: is fully awarer that the
statements made in this application for an operation permit are true, correct, and complete. Furthermore, the indersigned
agrees to maintain and operate the pollution control facilities in such a manner as to comply with the provisions of Chapter
24, Miami-Dade County Code, and all the rules and regulations of the department and also understands that a permit, if
granted by the df;,: ,ment, will be non-transferable and will notify the department upon sale, change of location, or legal
t s7 fer of the p facility.
r
Sig ature, ner or Authorized Person Typed Name
Subscri d sworn to and subscribed before me this day of 2000
Personally Known or oduce identification . DL#: C �_)'s _ //0 - 7 d _d
Notary Signature OFFICIAL NOTARY SEAL
AS
If signed b a Contractor or Representative, please check here:
LNOTARY PUBLIC STATEOFILORIDA
9 Y P OMMISSION NO.CC782914
OMMISSION EXP.OCT.132002
Company Name: a ep one:
Q m For'DERM Use'Only:
Process Date: f 0 v� Permit#: Check#:
Change of Ownership/ Business: Reviewed By VQ