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<br /> —= t ilAS T i U'FILE RECO 1(0 fl'' 'Olg4A 1(_JlNl FORM. ------�
<br /> ❑ Ncvy rH Program at 1:Xi5iiel;t"aciIUYaciliL}--
<br /> � � 0 0 W-7C4Record d 4)
<br /> � ���O
<br /> Facili0y Addlcv-1,
<br /> A U3
<br /> (Please Check the oppnopt;ate dCS,rip tio '?n td€pccify size, Dunibcr-o[uniis and r,cfZinen( ir,iorrnajr .)
<br /> i OOD PROGRia,Pri(1G00)
<br /> ®i:cstauranl: Scsting'apacity Square 1 Dotage Fond_u d:zndlers Lioui-s.„ n et,llirccl: l't=5 0 I`io k_1
<br /> ❑ Commissary ❑ Di-y storage only ❑ N�itlt Food Preparation ❑V nding Machines—Ilumber o[1lnits
<br /> ❑ lWail mirl:ei—Square footage ❑ 11rith I�lea(1113j ,t Only ❑ I'.Iultiplc DcpaFlmcnts ❑ Prcpack3rcd Goody Onl,,
<br /> ❑ Mobile Food Veizicle---I, al.e VchicicT)1 e Color
<br /> Registration U License.'4 Sticker#
<br /> ❑ Mobile Food Prep Uni(-1,11:e Vehich,"l T(-. Color
<br /> itcgistiation#
<br /> Licenser Sticker n
<br /> ❑ Temporary Food racility--Dates of opera-tion from to ❑ ice Pl1-nt
<br /> ❑ Speci:al Evcat --Dates ofoperation fmrn to ❑ L'rod!ice.Sbad
<br /> DAIRY PROGRAPdi (2000)
<br /> ❑ 'Grade A D.°icf ® Gr3de B Darcy ❑ of C'ontsiners in hili ti-?lead Unit
<br /> C up,p. ❑ State?~aci[itySurcharge(2399)
<br /> HAZARD OUS W AS TE PROGRAM(2 200)
<br /> El I 3-ardous Waste lGC2Cr3(oC-- ToiS 4 OIRCTatcd PCE�_ca-r ❑ J�CC3, f E--,.crilPi Sy'SiCn1(2299)
<br /> ❑ CRT Offsite Handlers(2216) ❑ Silver Only(22-2) ❑ Appliance Recycicrs (2217)
<br /> icrcd i'cranitlin a;,cFlity---- — ❑ Cuntii itai,.aily.R�_L,or-ciI(Ck) ❑ Coadit;onajly T-_:zcmPi(C1;)
<br /> -�}' B i'Fixed P f "-'.ulc.ti0 rc1 old l 3Z9rd,lLiS �VaSt�
<br /> ci itt-Ly-t.0 c, 1 IJ_lt U-1 4 ,'rLi 3p l
<br /> ❑ A R30 iq,:C_p GUt i1✓S c Gl CAGI n,�idit UACIL,1T a'(ASS(2390) 1'runtbcr t,[AST
<br /> UI`11DERG -OU1 fD STORAGE 11 A1\1L=(IJS'I� P .O�G1?%'..h;�1(2300) i ClST,4 ur�ll���r
<br /> [kJOUSING PRGGRtAV,11(2800)
<br /> ❑ llotc-ll1'stoiel I"lumbrr ofUniis ❑-ilzik nr L?,.ent�t nastitution --Idumbcr o[Unils
<br /> Emptoyet 1[.o:ssiag(2700) USO P"Mr,10 ffe.ffotr.si IC/_"C-bor Cal rp App icaeiarc 1'r?rnl
<br /> SITE(i'dU u 9GAT90H,(2900) UMD'ERG64GVJND RC-4.DEC-o RCiC:I
<br /> IJ k.t1Y?rOG�Ttf'ni 1/i_cSeSSi7.➢cL?t ❑ T1S h.-C ki,JuL= ® L cr'i LPN C1e-.Rip Site. ❑ 1--in,;ji✓L'GCl ."_nLp Site ❑ USC Sit`-
<br /> ❑ Abandoned l[Ibi'Sitc ❑. non-IJ2 •/Safi°C icaaup Sitc ❑Rl,-1,'OCB 'Clcar4up Site ❑ ah'ater d u2tity Re[aedi:a(ion Sitz
<br /> RE'CREA IONAL HEAL'o H t'[t0'GPAM(3600)
<br /> Number OFPOOIS/SPI-3 at Facility ❑ TI,jol ❑ Sp:a ❑ Out,af Scs-:-icy NoUSp,a ❑ Natural DsUiRgAU-Ca
<br /> VECTOR-CONTROL PROGRAM(4000) _
<br /> ❑ 3_'oulto,Unarm--Mg'ximurn number of birds ❑ [`cunei
<br /> u A'i a 00,B0DY t'[ERCiHG,PEh2MAHCH u COSii1ET6C PR%GGRJUA(x[101))
<br /> ❑ Ta Uo o La 9(4121) ❑ Body Piercing(4 M) ❑ L"c6-tmmac-at Cosmetics(1111'22)
<br /> tL.RQUID WASTE PROG[Z%'--t'=t(=1200)
<br /> ❑ Pumper ! Liccnsc It Capacity Vehicle i4
<br /> CI rumper Yard ❑ ICIT Gc3'iT!Cat PIaui- ❑ CLci7_,ical fl oilet= l?umber of Units
<br /> SGLOD WASTE PROGRAM(44D0)
<br /> ❑ L audlill ❑ Trr:asicr Staiio ❑ Ag/C, oncry IX,Sr, Sitr, ❑ S[ dgc/Asia Si(c
<br /> V.7Vaste'Tirc t7•aci1;y ❑ 'C,-,ill post 1;s,ci1 ❑ ll"roccss/vuc-,cl?n`zriIity ❑ ClA Laudf Sifc
<br /> L71.te[us,. '.'e11[cGCs—ldun?IacrofCIniU ❑ DumpsF.rs 0cuyd --C lumber ofUnii: ❑ lrarmJR.nchCtuauupSit,.
<br /> MEDIC.-AL V`IASb P
<br /> 3OGCANI(4500)
<br /> FA 1r!r-n.1}" A.eurtc C-r,j
<br /> S!n.flf G''cricr"tor ❑ P„e61!.ti C9}�1'1 t11C�
<br /> El �R`,3n=[cr JL3iU:is FJ �r. SCI Il`i _IiiJ.!C ❑ r�J�aipn 51,7,-dEC f;".CI[il}•..--- �I .� - 1U--I—! 11 -i�l.) ----❑ u����'nCfllLOr_
<br /> l'RIC,LRC"i`Ltid:mss• -S =�FFCiAPfTkC,G,RANI( 60+J) Us:'.x`11;"?'til?./IS-�7%-1)(J filrcc "i,1,li,.-?ii,rt- t.ir!r
<br /> CT PF(;S+'PP1
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<br /> � - � .� L'�•I-!•iIT' li/Iii' �i _ ❑ Ic'--iri Ili_rClcr
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