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GENERAL PRUWAR isle IMI <br /> FA_i LITY TD a �,. FACILITY NAPS �m� <br /> RECORD IDA Ptldt 9lms/enw <br /> _ DAIRY: Grade A trade B Ism Dispenser � natio of poettollyrs in NYIL -Now adt <br /> _ FOOD; Rsstwiront — Marm[t _ Ctamissery _ Mobile Poli _ /rm&wm Rstd — tet KwW <br /> seating Capacity 94 PY No Im to/toed Prep_ T f N <br /> Temporary POW FSltity, _ Special pond QYernt �.` vending +aceina __,,,, Rebar oP Vandiry Uniti <br /> Feed Vahiete _ Make - License 0 aeaistraticn 0 Color <br /> HAZARDOUS WASTE: Two Oaranated/Yr Tina PEANIT Facility CA _ CE — Pile <br /> IOMMG: "tel/Notal �. me. of Units Jai L/asaapt InetitutIM "Xing Abeteaiant , <br /> Employee aoutirg _,,,,_ NO. of PUw gfe0$ Approx Dates Of Oce;wPW _J_/_^ to ----/ _. <br /> LIM= WARM PunW Vehicle _ Pv"r Yard O,moiCot TOi Lets 00. PeakaDe TA Piens <br /> _ WDiCAL YASTRi Priwary, Care _ At�ta Care _ SYttte# Rtratnp _ Lit 0lmr'ator _ 9c Gpw7ter <br /> 510-099 (2-10) stores (11-SO) Lterage ( >50 ) Traelcfer SG _ ltd Hauler _ Vol Clinic <br /> �RiCREATIMU! HEALTH: PPoL/SM . Rtaber of Poots Out of serYtee Pool _ Hamra! Rathirg Mass <br /> / <br /> V SITE MITIOATICR: Jrwiron AA&M UST/LRPYoz Hate kaL Mat M% <br /> a <br /> Other Lead Agey Site ✓ Aq; yt ilk= OTSC _ RPL site — W/M Q _ other <br /> SOLID WWI: Lsr&fti Transfer 9ta _ Re-yel1P4 Fx _ ilaete SteraDt Pat `_ AR VaetdRmat Site <br /> SW V"Itte _ Na, Ota�ct'at' go. statio+err Comm ter site <br /> — VECTOR COMOU fbuttry Farr New Number of Birids ftnnet — <br /> EHEACENM YOTIFICATTOW for this FACILITY onVor PROGRAM J)AY WIMIT <br /> CONTACT T f l. �L /J SouS.¢ (r't_9) / ri r (_) -- <br /> MILNATED H�LOTEE Y L' PROGRAM ELEMEH7 Y 2( (� 5 C:&REi'I STAIus l <br /> e 3F LMITS ; CPA ID Yt - INSPECTION COOP ; <br /> SILLING andJIE ¢ILC-0GEHENI- I,e ,adrrsegnmd ewer, operator Or agent of same, ocko ledge that att Bite &tifur <br /> project specurly c assaeiate+i with thio fotility w activity rift be bitted To the party ideattlied as the <br /> BILLING PARTI .ta Ramify th®t I have ppred this application and that the wok to be wtrrwAd Wlll bo Goya <br /> in accordatnoi a SAN jOtWIN COURTY Oidinnut Codes and/ar Staderda ane Mgt enh/or Frderat Lara. <br /> APPLICART+S <br /> Tftle:�$c_\,IV X: _ Data. /IY� <br /> MSTTIDRIIATION TO *M AU INFO" <br /> M TION, in addition to the above, ween aped,.,(+, t, the owner, Ompoter or agar[ of 34o0t, of <br /> the property iaeatad at ebe ab" slte od&V$;S nerdy authartte the raleaea Of any and ail r"Ulte, RWteohnirat data and/or <br /> enVfronmentat/sine a=asament 'of*rmotfm to LAY .16AOUIN CmWTY PUNUC, HEALTH.URYILES E9V19CW VRTAL WALTH MisrCN as scan es <br /> it it av&ILAbte and at the same taw it is prwfdad to we or cry representative, <br /> Pee Amokot Moro[ Paid Det. of Paysoafit PayleMt Type Receipt i Check 0 kwvd By <br /> qq�� I �j� <br /> RM ,ZJ.L1_ Stn ������ Act'' �+?�.eYa'rr UNITCLK -77.. <br /> ua, <br /> �L- .�� WOE'S:SLI �Er"_T-TT-BER <br />