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A.D 1
<br /> I lew E I j Program at 17):istia Faci I it" X lb-v. C-11 Profjkl)l 3rid1,c, F.acihO,
<br /> S—
<br /> L
<br /> F,-1614 Addre's A,
<br /> (Plea.sc.Cbeck[he appropriate Jesccipti,3-9–LriJ l ccify size,r, -11hzr of units jrjJ pertinent information.)
<br /> FOOD FROGRZANI(1600)
<br /> ❑ Rcs',aurzal: Seating Capacity_ Square Footage Food 11-11idlOr-S Oldi SC i-e(qL1iFCd: VES El HO El
<br /> E] Cvmrniss-iq E1Dry--i0MgConly vA1 Food Prcp2la(ion DV.--adia- Alachiacs--Tlumbcr of Unit-s
<br /> 0 lWail Maiiet —Square footage El rri111 meat maa-et only El 1.1uhiple Depaj1n-,,:.,ms 0 Pr,:packagcd Goods Only
<br /> El Wbile'.Food VcllicL_ Ve I i i c I e T)T,,. Color
<br /> Ki.-gistri(ion,'I License 4 Sticker;rl
<br /> El Mobile Fo,,d Prcp Vehicle Type Cc,I,:.,r
<br /> RegiEtration r L.iccnsc 4 El ice I'laut
<br /> El Terapalrary Food Facility--Datcs of operation from to
<br /> El Special Ef-m't -Dates of op.-ration Cron to El Pro d uc: S(_ad
<br /> DAIRY PROGRAM (2000)
<br /> El Crad,- .dairy El Gride B D-liry ❑ M111,Dispco5cr-Humber o[O:.maincrs in Huld-lic-ld Unit
<br /> CUPA Cl State Facility Surcharge(2399)
<br /> jjAZjkrwOj-1S WA3TE VROGB-k .i(231,0')
<br /> El flaz3rdous Waste Per Yeax L ucy,- ir,(S;i al(2299)
<br /> 0 CRT Olfrslte 1-h-ndlecs (2216) 0 Silver(Drily(2222)
<br /> Tiered Pcruoittin.7 F-acili;)' El Aiulfliorizcd(CA) ❑ CoaditIOL1311Y Exciiip(((_E-)
<br /> 0 P,cm-ii[-By-Rule Fixed Uni( Cl wzs(,;
<br /> El A B OVEGROU11D STG-11
<br /> Oa (AS 39 ) TlumbCrOCAS T
<br /> - _ �Z T AINK 2 0
<br /> UNDERGROUND STOU,--CE-A'A-J-qK (2300)U-7 USTA q-3 f (c-ors-
<br /> c-i o us I[I G -. a 0 G R.,-k M(2s 0 Q)
<br /> D 110(cnlo(el—Numb,-[of Units ❑ Jail cc',Tempt ins(itu(;o1i
<br /> Employ:110 r:Siag(2700) Us._-l nrprti usin jT,-,b(7 r Clif(17,4ffl[iC-1 60 iTFC177-1
<br /> SITE MITiGATION(2900) UMDER.GROUND 1MJEG-CIOM COHTROL(3000)
<br /> 0 EaAroairmi(al Asscssmca' 0 WJ STI.C A P Site L^r!1171 Clcfu 1!p Silt CIC.Iaup El ji i c-1c, (e
<br /> EJ Abandocled IM'Sita El nc-r-,-NPT-.iSEP ClCaflup Site 0 RWOCT- Cleanup Site 0 Sit,.
<br /> RECREATIONAL HEALTH PROGRAN*1(3(100)
<br /> I-lumberol'Pools/Spas at Facility ❑ pool ❑ Spa F
<br /> Ou(of Senict,-;,00USp-t (L'rI D, acilip a
<br /> V2GTOR,GOHTROL PROGIV4(,1(40013)
<br /> El J,ollitul,Farm--Ma I ximurn number of birds ❑ Kennel
<br /> TATTOO.DODY PIERCING,FERMAHEN7 COSMETIG PROGRAM(4100)
<br /> EI T2[tooing(4 121) El P,c d),Vic rc i ri g 0 1 ZO) ❑ Verj-uiueat Cosmc(ics(4122)
<br /> LIQUID",'(ASTE MOGR-M':1(4200)
<br /> El piimp�:r Cap2c iLy vdlicic 4
<br /> El P a mp z r Ya rst El cLkmuic A YA lets:—1-fu mt,er :,f till iL.-,
<br /> SOLID WASTE FROGR-M.1(4400) D Slud,,,e/Ash Site
<br /> El Liadfill 0 Tr:1us[cr3Mion n C r-f'%VA S(Q Si(,. L
<br /> 95k3T",F, ZciliiJ F-1 {-,:)i v r,o s c i 1-D i'fouss/T.Zecycl-.F_CiHO, ❑ CIA LaridFill Si(.,
<br /> El Rcru-,, —]-Tuwlj.[ ufl loit- C1 POITIP-hcfg>20 cu yd —Plumber of Units r[".:1aup' itc
<br /> kJEDIGAL IASTE PF-Ou'R.-Al"I(J01'j)
<br /> El El I,ij r C-1 C] �i-11311 11.1-1I F
<br /> El T C. R i i;:n
<br /> I Zi 2 L i i-= (.o,f I-c7 z F
<br /> 717
<br /> 10/1
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