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/.�sil°iG~' _.!•_. r :'::'.�$�xa;:- ._. '•�,ti's:... _' - - <br /> 05-114-1997 15:42' P.02 <br /> Nsw 41yam_ni <br /> •. T�'�� .. �;i�irige ` � Of t (pR00?) rwind 5Rt/93 <br /> n K/A fACiLITT MAW�MPULA ` <br /> len[ tsda A 'f'Orade`D tt° Milt Diapiss@r Mnsbor of Containers in Muttf•Rsad Unit <br /> .i:�, 1 <br /> ttirtslM'tft` c Market C, Invary Mobile food ►rodacr hard 1n Plant <br /> • �� -�"•;' f Market w/fesd rr t T / M <br /> .. �"=msttf+♦ �aga@ttlr s4 t �T' <br /> fat food [vent vending fiochines Rtsber of Vending [)nits <br /> ,�,,•,, •�. �,Twporary food Facility spat <br /> W6lot* Mak' License ! Rsglstratieri IF Color <br /> :•.;,.::1N: IIIZARDOUi MIUS Tana Danaratsd/TP TIERED PERMIT fecllity t CA C! MM <br /> NOtJ:TDOs Ratal/lletal No. of units Jail/1xerspt institution Rousing Abstarnent <br /> ttaployeMt Dousing No. of Exployees Approx Data@ of Oecupsncy _J / to <br /> LIsYiD 1tAfTlt Ragor Vehicle Pusper Tard CIM"Ical Toilets No. racks" in plant <br /> 1EDiCAL WiTEt PrIftry Care Acute Care skitted Nursing LD Wwatof SM Canarstor <br /> Storage (2-10) _ Rafe" (11.50) — Storage ( >540 _,. Transfer Sts _ Ltd [levier _ vot Clinic <br /> IMCREATICIIAL RIALTR: ►oeilSpa Mtrber of Pools out of lervict tool Natural tathfry Plan <br /> _ St T! MITIGATiams Envirtn Assess UST/UAP Loc Paz vests Nat Mat "t <br /> Other Load Avency Site Asentyt Ruo" DISC RPL lite b/R2D tl Other <br /> SOLID WlTEI Landfill Transfer Ito tecycling Inc Vasto Store" Fac AS Yaste/Exeapt Sit* <br /> �- <br /> Ski vehicle Pa. Durp%%er No. Stationary Compactor Site <br /> VICTOR CdiTRC✓lt poultry Form Max IRsber of girds Xv. t <br /> DoUnOW MOtIFICATION for this FACILITT and/or PRO" DAT Rim <br /> CONTACT I's ( ) ( ) <br /> CONTACT 2 ( ) ( ) <br /> aEII ATB 6WWM • I PROGRAM ELEMENT ! MINN NT STATUS <br /> ! Of WITS 1 IPA i0 IT: InKCTid1 MR <br /> iILLING and CONK1ARCE At701MEMV eRTt i, the undersigned caner, operator or agent of $sear, ocbvwtv** that all site and/or <br /> project specific M/M haerty charges associated with this focIlIty or activity wilt be bitted to the party identffled as the <br /> 1ILL(Rif PARTY an this farm. I stao Certify that I have prepared this eppticatfan and that the work to be performed will be der <br /> In occordones with all apptieabio SAM JOAOUI TT 0 name Codes and/or Standards and State and/or federal two. <br /> APK:CAMTIS SIGNATIM <br /> X1,;0- C O�'n'� s19'�7� 1'(rRc 1 Gl3 <br /> Tftiet Ostet <br /> AUTRORIZATia TO 1tKUK INFORMTIOIt In addition to the above, miner[ owlicable, I, the owner, Wee for or agent of saws, of <br /> the propertyloested It tie $bow site oddresl hereby authorize the release of any and all results, *eetechnfest data and/or <br /> onviran wntoi/sits atmeament information to SAM JOAOUIM CWMT1' PUBLIC )WEALTH SERVICE! EDVIROMiENTAL KALTN DiYI$ICN me soon as <br /> 1t is evellaMe std at dw same tfaw it is provided to r or my representative. 1i(/U 7 6, a <br /> he Asao,&M Aiosnt paid Date of Payment Payment Type Receipt ! Check It Recvd fly <br /> 10 <br /> NEAS SWY �/ / ACCT UNIT CLIC _/�•1 <br />