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CcrtERAi PROG3Ati FILE Ntae Gyange Edit Adak <br /> _ J (PROc'>3) Mised 5l21/43 <br /> FACILITT ID t FACILITr HAMS <br /> �j <br /> PECUM 113 1 I /� 1 — PR DOR ST ap'lI�}{P / <br /> OAIRT: Grade A Grade 3 Nilk aispvnoe Aurber of Containers In *JW-4ead Unit <br /> FOOD: Rastauranc Markle Camaissarr Mobiles Food Prodaae Stand Ice Ptant <br /> Seating Capacity Sq Ft market Wood Preps T / N <br /> Temporary Food Facitity Speciat Food Event Ye:rdIrq Machines Autber of TvsdIng Units _ <br /> Food Yehicte Make Llctnse ! Registration 1 Color <br /> I <br /> HAZARDr31s VASTE: Torr Generated/Tr TIERED PISRMIT Facitity : CA CE pqR <br /> HOUSING: HoutMocat No. of Units ,fail/Exacpt Inatitution naming Abatement <br /> E=(ayew Housing No. of Esplayees Approx Oates of O�apency _�_f to <br /> LIQUIG VASTE: Ptwpar Tahieta Pumper Tard Cseaeieal Toilets No. Peekage Tx Plane <br /> MEDICAL MATTE: Primer/ Care Aceta Cue Skitled Nursing L0 Generator Sot Generator <br /> Storage (Z-IQ) _ Storage (11-50) _ Starage ( >54 ) _ Transfer Sts _ Ltd Haular _ Yet Clinic <br /> REUSATIONAL HEALIH: Pont/Spa Nunber of Pools out of SerYiea Pool Natural 3athing Ptaea <br /> _ SITE MITIGATION: emi ran Assess UST/GAP Loc Raz Vaste Raz )(ac ?P! <br /> Other Lead Agency Site Agencr! 2LAG3 OTSC NP! Site RB/T= 0 Qther <br /> SOLID 'TASTE: LardfItL Trsnsier Sts Reeyeting Fac Vista 'Storage Fse Ad Vast&/EXame Site <br /> SU `lwhictw go. X ostar AQ. Stztlonmry Ctucector Sita <br /> _V_�CTOR CCATROL: Poultry Fara )last Ntaaber of Birds 1C.L <br /> rtERCENCT NCTIFICAATIOM for this FACILITT andlor PltO= M OATNICHT <br /> CONTACT 1 ca , (e�I�-_CL"-/1_/ ( ) <br /> OESIC:t11TF� �CO7E5 = V PItOGNAM EL7iF�lT ! � axjtERT :TAT IM <br /> 3 Of U7tITS V EPA to !: IXS?£C;It'Dt CGDE : <br /> 3ILLING Mrd CCFeP!IAX=- AMMULEDCDCUT: i, the widersigned owner, operator or agant of same, 3ctrj +iedge that all site and/or <br /> project 3mc ifle PHSIM how(y dsarges associated vith this facility or activity viLL be bilLed to the party Identified as the <br /> 31ILLING PARTY on this fors. I sisis eartify that I barn pretend this avoileaeion and that the writ to be pwe-foeviLL be dant <br /> in acacrdwxv vi th all acpl tcsble S UI MAXIM CaXrr Ordinw=@ Codes or Starzlards and Stats or Federal Lasa- <br /> APPLICANT'S SICIATlstE : <br /> AUTR=MTICX TO RELEM tMFOWTION: In add1tiA to the above, Own sppliobis, I. the oersar, awratar or agrrrC of sane, of <br /> the praaerty Looted at the above sits adds*sa hereby authorize the rtlease of arty and At results, geotacsniesL -Jars arsdlor <br /> esvirormental/sits ass+rsment Inforertian to Sall JL1ACl1111 t=LDQT PMIC 1EAUR Se"MI=- -3(V12 WcF_TAL AMIN OIyISICtI ar soon as <br /> it is availabte and se the sam time It Is provided tower or sy rvgr*sarreative. <br /> Fele Amouie Amount Paid once of Prtment P:yoene Types Aecuipt t Cleck ! Raced 3y <br /> -Iff_1&q� tA 0 <br /> _AAAA_..__.. ............__.._ .. -•— -.. . ..._.._..__AAAA _.. --- -AAAA__ AAAA.. _.._AAAA. ...•--�= .. °-•--..._. <br />