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;(�I�L4C`? ➢l`?1,,iE["!'9, ',,L tl' I,TA1 V��^I.l'rtit..
<br /> 1 :IC x.-
<br /> ___iti'i_'..S�4�R.E•II;1� I:I?4� ?Iti! Ilil�vl�'.1`r1�`_TIC11d i'C)I�.1�i =___ --- --
<br /> ll-vr riI ProO•raITI al i_.- i2tiegFa ilio,ED
<br /> I.citify [�11c;_r Lfl 1'roi�gr �m, rl�1`Ic ,.?g_iilit'—
<br /> 1"knn( S70- a'.rr_:�.ramAccord iD
<br /> 9�aci[i(-,r Addu,ss 5 Na e1�Or, lye oc, 'oma
<br /> (Plea-w ifu;cl:the nppropti-iti�descriptiou and specify is,=,number of units and perfinent information-)
<br /> FOOD PROGR.!ll(1600)
<br /> ❑ titcslsuraei: Satin i'-ar,acit)' Squaic Footage Food 11.1ttdlers e=ours" requircil: IES ❑ NO ❑
<br /> ❑ 'Commissary ❑ Dry stc rage only ❑ nth Food 1 repsation D'cndiag!\lacbiacs -Number of Units
<br /> Tltetail Mail et--Square footage ❑ vrill lac-at i\laiket only ❑ Multiple Dcpartmcnts ❑ Prepackaged Glood>Only
<br /> ❑ Mobile Food Vetfick ---1`,ialce Vehicle T)T,e CoIur
<br /> 1;cy;istration lI License it Sticker it
<br /> ❑ Mobile mood Prep LJuit-1'Sal.c Vehicle Type color
<br /> ;SCgisir tion:# License rf Sticker n
<br /> ❑ T empor._ry Rod Facility---Data of operation from to ❑ 'ce Q'laat
<br /> Cl Sprcial Eycuf --Date-of op:ration from iu ❑ 'Produce Sta❑d
<br /> DAIRY PROGP-AV:!(2000)
<br /> ❑ Grade]Uairj ❑ Grade B Ll NO: in Multi-head Unit
<br /> cup! ❑ Stale Faci[ii),Surcharge(2399)
<br /> lv4:/j,kRDOUS ii'i>,ST E PROGRAM(2200) i
<br /> Elllna rLults`1`:,sle C aerator-----Tons Gjencr-tcd fICE-Yeat El Recycle/t emp(System (2799)
<br /> ❑ CRT Onsite Ii ndlers (221E) ❑ Siiarcr Only ❑ Appilatu_e Rccycicrs(2217)
<br /> Tiered Pcrrhiiliri Facility--- ❑ Coaditio!2:11y.AuLori7cd ❑ Ca.-2d E'xcnrPt(CL)
<br /> El ¢er,,,it-3ly-i;uli. Unit ❑ I'crnLi Fly-l,ul_lloi-se'!-lold ili-:ctrd,i Waste
<br /> Ah3mT-GRtJ'U11DS-foat"Gr IftUrlK-CAC-(UT'��'(AST)(2"0) IlumLcr of AST
<br /> UrlIDERGROUHL)ST op-- E',JJK(USP)P1-.GGILr'=Il1(2300) �`/;� U,STA an,l F,
<br /> 1{OUSI[ IG FROG-Rll-1'':l(1-10(J)
<br /> ❑ Alotcl 1 1o(et 14uriibcr of UniLs 1-Vzil or Ti-,)m t 'astitrstioa--1 lumh,r OCUnils
<br /> Emploti'_:Ito using(2700) Use l?nrrifol'ee A;usiaCAT aboi-Caurp Appficafior Fol-11I
<br /> S1 a R Fvii-1 IGF T MN(2900) UMDERGROUND INJECTION COr--i T ROL(3000)
<br /> ❑ EuArommcabl Assssntent ❑ UST-r--Al-Sit, ❑ 1Loc21 MV C"leauup Site, F-1 1,4PL lSEC Cluanup Site ❑ h1Tc Sit,
<br /> ❑ Abandoned'iMYS{ir ❑ noa-M R.iSEV clC llupSite ❑l,VVQCC CkartUp Site ❑ QI-alilyRcrnedia(ion Sitc
<br /> RECREATIONAL HEALTH CROGRAVA(3600)
<br /> Numbcrof pool-/Spa--. at f=acility ❑ h}cl ❑ Spa ❑ 0uf of Scn ice Pooii";pn ❑ I1 .turaI R-afliiri f_vc i
<br /> VECITOR MiTROL PROgC?1JA(4000)
<br /> ❑ Poultry Farm 1Pt:Ltimr-ICn rnufrbcr of girds ❑ 1_cnuel
<br /> cATTOO BODY PIERCING,PERF-1A dEN T COSMIC KC PROGRIVil(41w)
<br /> ❑ Tattooing(4 121) ❑ Dcdy Ner-'ng(4120) ❑ L'ei ;eeat Cvsmciic (4122)
<br /> LIOUID WASTE PROGRArl 0 21)0)
<br /> ❑ Punl,per VCIikV—RCgifirLtlon F _ License Ir a.pacity Vehtcic 4
<br /> ❑ Pumper Yard ❑ ''icl ;c 3"restr:i::;,t-''!:,at ❑ 4 Lca_ic,i Ti oil,,(_ jrumi:,er oCUmL;
<br /> SOLID'v'dflSTE PROGRAM(1-100)
<br /> ❑ L-audri[l r❑�� T ip�ferSt,[inr, ❑ :fig l C.._arncry VV., t;:,Site ❑ :Mudge/,asb Site
<br /> f tr t ,i i� I 'r��ompo t C[!ll)' ❑ 1'ro CC�S�YeC rI:` `:aClltt ❑ SIA afldtlll JItC
<br /> Ut Fr2ste 9irc:.i_.li. 1.- }'
<br /> ❑ Refuse +'ellic(c<-Number^t Units �l Ltun1( .icr:;=Z0 ':ti 01 —I IulT.ibcr Of Unit; [ 1 "nVP-;i:aecls cl anuli:'Qiir
<br /> (MEDICAL•v"J113TE I'rCjf-R/1i,'t(.!500)
<br /> f'i�Fri ary rC ❑ �'l^,qtr (�9t-f i_I ,y l; t!,.,j i.'[t,f ding Sm III C'urlr -tor ❑ Lirlitcd iITul^r
<br /> ❑ I.6-'.rrfor r:iLt:.i1 �- _ied:1 , '_7ti11•_ 1�I , �-�,•-�i r7❑`�i]-'lE - ��trt)"---� � - 7(J. ❑ l� -lJ l.) —❑ :I)f':OCt a.t;if>
<br /> lFU(3L[C';I'ATE
<br /> -I'AGa==-I' GT!-ll'Cif0eff : G i:lift - :,f !LPI ' ufrl� 'kt�'C
<br /> II 1!II'llt t'll
<br /> li/ ?0_ -_ _
<br />
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