CC-18-902Department of Regulatory and Economic Resources
Environmental Resources Management
MIAMI-DADE 701 NW 1st Court a 7th Floor
Miami, Florida 33136-3913
T 305-372-6600 F 305-372-6410
GDO No: 9122017 miamidade.gov
Fats, Oil & Grease Discharge Control - Operating Permit Application
INSTRUCTIONS: Provide the appropriate information for all fields denoted as required in each section of the form. Incomplete applications will NOT be
accepted by the department until all required Information Is provided. Refer to the permit application guidelines sheet for processing locations, fees, and
other relevant information pertinent to the completion of this form.
Application Type (select one)
New Businessioperator
Transfer of Ownership or Name Change of Existing Permitted Facility
XD Modification of Existing Permitted Facility (includes modifications to FOG control devices, modifications to facility size/area and changes of use)
B. Applicant Information
'Applicant (corporation, I.I.C. LLP, sob proprietor) Publix Super Markets, Inc., Publix 794
Applicant Mailing Address": (Attn. ESP) PO Box 407 Lakeland, FL 33802-0407
2Authorized Representative Name": John Attaway Title Sr. Sr. Vice President / General Counsel
Email : John.Attawayfpubix.com Phone No. : +1 (863) 688-1188
**Denotes Required Field
t) If applicant is a conporty, corporation, partnership or similar, the name speciflad shall match the name of the corporate entity that is regstered with the State of Florida Division of
Corpora ns. A fictitious name specified on the form Mail be preceded by the name of the erft or individual (d sde proprietor) that owns said fictitious name. For example, "ABC,
Inc. dlbla XYZ Store', where "ABC, Ina* is the name of the registered entity that owns the registered fictitious name -AYZ Store'. Please refer to llpt w sunbiz. g for the listing of
corporate errWas and fictitious names registered with the State of Florida Division of Corporations
2) A separate letter of suthorization shall be attached to the application forth if the individual specified is not a registered offloer of the corporate entity applying for the permit. This
reghtiicmem is not applicable if applicant is a ads proprietor provided that the sob proprietor is the individual signing the form. Note that names of eomraetors, expediting services
providers. or any other Individual providing similar services that is not Involved in the management or operation of the facility shag naLbe gated as an authorized representative.
C. Facift information '
Facility Address (Street, City, Zip, Unit) : 9050 Biscayne Blvd Miami Shores, FL 33138
Facility Phone No": +1 (305) 7514075 Facility Email: Brenda.Williams®Publix.com Property Folio No.»: 2,822,030,250,030
»
Days and Hours of Operation : 7-days a week; 7:00 am- 11:00 pm
"Denotes Required Feld
Dl Facih�I Use Information
Select/Describe Use that best describes the Facility"
Apartment/Condo/Club House
Banquet Hall
Child/Adult Day Care
❑ Full Service Restaurant
Assisted Living
Cafe/Coffee Shop
CommerciaUlndustrial Bakery
Processing/Manufacturing
Bakery (non-commercial)
Cafeteria
Convenient Store/Gas Station
❑X Supermarket/Market/Grocery
Butcher/Fish/Meat Market
Catering
Fast Food Restaurant
Take -Out Restaurant
Other
"Indoor Area: 51.420 ft2 "Outdoor Area: 0 R2 No. of Seats: Drive Thru Lanes: []Yes 0 No
Fab, Oils 3 Grasse Control Device In6cinnation
List all FOG control devices serving the facility -
No.
Make 3 Model
Material (Metal, Plastic, Concrete, other)
Capacity (gpm or gallons)
Location (Indoor or outdoor)
Not specified
Concrete
1,250 gallons
outdoor
GI-1
Not specified
Concrete
1,250 gallons
outdoor
GI-2
Not Specified
Concrete
50 gallons
outdoor
GI-3
**Denotes Required Field; an operating pemhi will not be issued until the facility has a department approved control device. Page 1 of 2
. CERTIFICATION BY XPLICAW
•""COMPLETION OF THIS SECTION IS REQUIRED —
The undersigned authorized representative of (name of applicant) Pubfix Super Markets, Inc.
Is fully aware that the statements made in this application for an operating permit are true, correct and complete. The undersigned understands that
discharges of Fats, Oils and Grease to the public sanitary sewer that exceed the standards set forth In Chapter 24 of the Code of Mian*Dade County
(Code) or in quantities that may affect or hinder the operation of the sewage collection, transmission or treatment facilities is a violation of Chapter 24 of
the Code. The undersigned certifies that he/she is fully more that the submittal of a permit aRrllication does not guarantee issuance of a
Devk efs) Ware) approved by the department for the facility_. It is further rJtn le at a permit, If granted by the Department, is not
transferable and that notification shall be provided to the Department n a a e 1p or relocation of the permitted facility.
John A. Attaway Jr. -7&5 Zo i 2
Name of Authorized Representative' Signature of Aut4rod resentative- Date
Subscribed & awom to and subscribed before me this e2q-6day of 2018
Personally known , or produced identification . DL #:
Notary Signature:
+fl`;:��•":tte%RABETHBI"MEY
* * MY COMMISSION I FF 121178
Notary Seal EXPIRES S90fter s, 2018
�'aor e«aianntiee�alloeryt;,n�„
Notary Commission Expires 0j&jr j/$
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•A notarised letter of authorization shall be attached If the name of the Individual does not correspond to a registered officer of the corporate entity applying for the permit,
as Indicated in section B. This Ntter is not required for sole proprietors provided that the "Applicant" and "Authorised Representative" specified on the form match and that
the application Is signed by the same Individual. Names of contractors, espedhing services providers, or any other individual providing similar services that is not Involved
In the management or operation of the facility shall sat be listed as an authorized representative.
P. •CERTFICATION BY PROPERTY OWNER _
'MIS SECTION IS NOT APPLICABLE IF APPLICANT IS SAME AS PROPERTY OWNER*
The undersigned authorized representative of (legal property owner name)
is fully aware that the discharges of Fats, Oils and Grease to the public sanitary sewer in quantities that exceed the standards set forth in Chapter 24 of
ithe Code of Miami -Dade County (the Code) or in quantities that may affect or hinder the operation of the sewage collection, transmission or treatment
facilities hr a violation of Chapter 24 of the Code. The undersigned certifies that the operation and maintenance (cleaning) of the Fats, Oils and
Grease Control Devicefs) serving the facility is (select one of the options belowt:
The responsibility of the Legal Property Owner.
The responsibility of the Applicant listed in Sections B and F of this form.
Subscribed & sworn to and subscribed before me this
Personally known
Notary Signature:
ft"ignature of Authorized P
;5: -1--k day
r
F,, PATRICiACOOLEY
MY COMMISSION # FF 11409
Notary Seal ' EXPIRES: August 20. 2018
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DL #:
Notary Commission Expires
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Date
"A notarized letter of authod I = shall be attached if the name of the Individual does not correspond to a registered officer of the corporate entity having legal ownership
of the property. This letter is not required for sole proprietors provided that the Authorized Representative specified In this section of the form is that of the legal property
owner.
1II. PERIMIT APPLICATION SUSWTTAL CND - —
All required fields of permit application form are completed. zoning Certificate of Use/Occupational License Application Form.
[] Applicant has read the instructions provided in the permit guidelines sheet. Permit Fee (see guidelines sheet and fee schedule).
FOG control device information is specified.
Form is signed/certified by a duly authorized representative of Applicant.
Notarized letter of authorization by Applicant is enclosed (as applicable).
Form is signed/certified by a duly authorized representative of Property Owner (not required if applicant and property owner are the same).
❑ Notarized letter of authorization by Property Owner is enclosed (as applicable).
Page 2 of 2
MIAMI"DADE
Department of Regulatory and Economic Resources
Environmental Resources Management
701 NW 1st Court • 7th Floor
Miami, Florida 33136-3913
T 305-372-6600 F 305-372-6410
miamidade.gov
Fats, Oil & Grease Discharge Control Program - Permit Application Completion/Submittal Guidelines
A. Regulatory Requirement
Pursuant to the provisions of Section 24-18 of the Code of MismikDade County (the Code), an operating permit Is required for any non-residential facility with the
potential to introduce oil and grease Into the public sanitary sewer system in quantities that have the potential to affect or hinder the operation of sewage
collection, transmission or treatment facilities. The Intent of the Fats, Oct and Grease Discharge Control program Is to regulate facilities with the potential to
Introduce on and grease, commonly referred to as "Fats, 01 and Grease" or "FOG; to the public sanitary sewer systems of Miami -Dade County. Facilities with
said potential are required to obtain an operating permit issued pursuant to the provisions of Chapter 24 of the Code.
B. Permit Application Form - Important Tema to Know
The terms listed below are referenced In the permit application and are hereby defined to assist the reader in understanding the scope of the various sections of
the forth and to ensure that the required information is specified accurately.
Fats. Oil and Grease (FOG): common industry/regulatory term that Is synonymous to the term -on A grease".
FOG Control Device: pertains to any equipment designed to remove, hold and prevent passage of FOG to the public sanitary sewer system;
this includes grease traps and grease interceptors.
FOG Generator pertains to any non-residential facility that can Introduce FOG to the public sanitary sewer system.
Applicsnt: is the person or entity intended to be permitted by the department that shall be responsible for complying with the conditions of a
FOG discharge control operating permit This includes sole proprietors and entities registered with the State of Florida Division of Corporations
such as companies, corporations, partnerships, eta
Facility: refers to the establishment (place of business) where a FOG generating activity is conducted; see "FOG Generator" definition above.
enft Owner: refers to the legal owner of the facility (premises) where the FOG generating activity is conducted.
Authorized 1IMmsentative: is a registered corporate officer (e.g., managing member, president, vice-president, eta) of an entity that is duly
registered with the State of Florida Division of Corporations (e.g., corporation, eta), or a sole proprietor. If the individual listed on the
"Authorized Representative" fields of the permit application does not meet the aforementioned criteria, a notarized letter of authorization
Issued by a registered corporate officer or sole proprietor (as applicable) shall be attached to the forth.
C, Permit Application Form - When Is the submittal of a permit application required?
The submittal of a permit application is required for:
• Any new business/operator (FOG generator) intending to operate within Miami -Dade County.
• Transfers of ownership or name changes of an existing permitted entity (i.e., permit holder).
• Updates to permit or facility information, including (but not limited to) modifications to FOG Control Devices, modifications to facility
sizelarea and changes of use.
D. Permit Application Completion and Submittal Instructions
General Information
All sections of the "Fats, Oil and Grease Discharge Control Program Permit Application" form shag be property completed and certified by all parties responsible
for the operation of the regulated fact ty/establishment, management of the FOG control device(s), and having legal ownership of the fadlity/establishment. An
operating permit shall No be Issued until the department has determined that the application is complete and a FOG control device is approved for the facility.
Zoning Ucensing Requirements
The FOG Discharge Control Operating Permit Application forth shall be submitted in person to one of the locations listed below. If your facility is located within a
municipality, the application form shag be accompanied by a completed Certificate of Use forth (a/ids as "Local Business Tax Receipt* or "Occupational License")
from the municipal zoning authority having jurisdiction over the property. If your facility is located within unincorporated Miami -Dade County, note that the
submittal of a Zoning Certificate of Use application will be required at the time of submittal of the permit application forth. In order to process the permit
application, please ensure that the Information captured on the permit application form matches the information referenced on the zoning application form (either
municipal or unincorporated).
Procaasing Location
Address,
$twee Facilities Located Within:
RER/DERM - Overtown Transit Village
701 NW 1st Court, 2nd Floor, Miami
Municipalities Only
RER/DERM - Hialeah Satellite Office
501 Palm Avenue, 2nd Floor, Hialeah
Municipalities Only
RER/DERM West Dade Office (MDPIC)
11805 SW 26th Street, Miami
Municipalities and Unincorporated Areas
The fist of fees pertinent to the Issuance of Fats, Oil and Grease Discharge Control operating permits is found under the 'operating permit fees" section of the
most current version of the departments Fee Schedule. The fee schedule is available online at:
environmental.odf