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<br /> tlIASTERD LE REC01 INF0R111ATI 0N FO P" 'I_
<br /> ❑Mv;E-H T'rogr ni at E istiar Facility k'rogrsm amu i l•:_v 4_icilit.ti_
<br /> i'actlit A➢_____� __ - _O®� _d�,,�i�ratiz IZccus d l.l.T
<br /> 71 CU_AA
<br /> FacihL-
<br /> (Please Check the appcopriialP t7c Durtil'N-4J�YtS Jf1d Pei'itn°nt
<br /> FOOD PROG€JAI':I(I GOO) _pp
<br /> ❑ 1'eslauraat: Seating Capacity Sgtlaru 1=ilvf3�e 1'006 1and[CFS COUFS'L N egtlircd: YES ❑ NO �Y
<br /> El Commissary ❑ Diy mot-age only ❑ tvitll Food Pfglration ❑Veodia-Machines -T?umber of inits
<br /> ❑ tctaU ftlarkel--S-quare.lootsge ❑ wiGh 1',1c:at 1Aarl,ct only ❑ Multiple Dcpaclm_nts ❑ PfQpacl:".Pcd Good-,Chzly
<br /> 1=l T�dvbile Food';'chicle--T:41ce Vehiclz T,,-C,e Colur
<br /> Registration# Liccnse i'; Sticker Ft
<br /> Cl 1�1oUile Food Prep l_lflit-T.Icke. Vehicle TyT++; Color
<br /> Registration 4 License N Stici,er n
<br /> ElT€mpuF ry llioad FaciIity•--Dales o[operation 1-rorn to ❑ [cc f'I,nt
<br /> ❑ Spe-cial Evcni --date oY operation irons to 0 'ro duce Sbnd
<br /> DAIRY P OGRANA (2000)
<br /> ❑ Grade A D24 J ® Grade F3 ry 13 t,lill_E)1;S,cr1;cr--tlumbcr of Containers in i`,iulti-[1�_ad knit
<br /> C,upjr% ❑ State l±acitity Surcharge(2399)
<br /> 11_4Z7A_JUOUS WASTE PROC=1-+2,M(2200)
<br /> ❑ 113Z.21"f104dS Waste(C:n.l,r:'tlt'i('.---- of-Ls Ccnetat:_d Ica-'.eaz ❑ JZC�j'C1C l ILuCl�111t S}'S1CFE3 (2299)
<br /> ® CRT Offsite Handlers (2215) ❑ Silvrr Only(2222) _ ❑ Appliance 1:ccycicrs(2217)
<br /> Tier,c,d Pc n,iUing F.-Ifu ty•..---•—.-----El Candi.tiooaily AufLoriLrd (C,,'L) ❑ Goncditionally Excnlll((CE)
<br /> C� a e,,;i-i3y-!_mule Fi:ccd'thit Y=t a'cmui-a3y'-i'.ulc 11.-CTzold il,, n_uoLs W.astc
<br /> ❑ L4CyV1�Gk���JNk?STU L�f Lr�1 f1i RF.CitUT_��.'(AST)(2390) 'Hun-:bcr;ll AST
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<br /> 'UNDERGROUND 5T(�1��'_GE,i?r-i`iP,:SUS'T7 t_I_�.0��>�_,UA'I(2300) i1s.- USi A ar,,f 1: ;,,,,s
<br /> pi;OUS1[IG P ?tDGC Sys(2400)
<br /> ❑ :r1.o(eU1Aok1--T`!un-11f of Units ❑ -Iil Itr t.'ieulp, Mstlfu(ion.--1`1 ui111:�^C i,.�l.JnitS
<br /> Ea ploy«li'osicin (2700) Use.JSnrF,[aree Ffntrsire�,7,1P_,ar Camt!Phficaii�ut I�7om
<br /> S17E E Cali tl 9GF m M(2900) Ut'IDEI'GROL7ND 9 JEC 9 900 'i:-OH B ROL(3000)
<br /> 7 av?roc i nr':11 Assessment ❑ S-i-CAP Site ❑ Lo c a I L 4V C1eanup Site. ❑ N L.iSE_.l.'C'C: up Site ❑ Luc Si(
<br /> ❑ Abandoned I5V Siic ❑ moa-NPLJSEP A-_I namo Site ❑ RV QC.'P Ck-nuuFf Site ❑ ':',`'ter Quality Ru-Liedia(iou Site•.
<br /> 9zECRt=nT eaNrae HEALTH PRaGRara1 _
<br /> rlunlbcro[Pool_lSpas atl�acility F11,q o1 ❑ Spa ❑ Cut oCScs-r'sc:_h oalJS,:_x U T(,:fl ra1Lt_Lir�f'cre2
<br /> fLC'9 0R Ct?Pl i"ZOL PROGRAM(4000)
<br /> ❑ roultn'i arrt--Nf_1':cimum number of birds D Kccnel
<br /> TAdo000.BODY PEEcCUJG,SERMAHE.C•9T COSPAET9C(i RUGRAM1(4100)
<br /> ❑ TattaoLag(i121) ❑ ptodyP� creinr(41110) ❑ PeM12LncatCosm.c(ics(4(122)
<br /> UQUID'r ASTE PROGR,_,MA(4200)
<br /> ❑ pumpec S 0dcle-P egist�ation 4 _ License it Capacity vehicl,c if
<br /> h untper S'zrct E.1 llacLag e Tr eatmaat Naas- ❑ C1 cn_?c:l T oile'.s i iumber oC Unit;
<br /> sc9-9D
<br /> r1r Ic F-1Sfadge/,?sh Site
<br /> TransCa°rSh?ioaa ❑ AFI Cranncryll:_[ ��tc
<br /> xf ,"f,,'lrteTirc F,�.,C;Iiiy ❑ Compost Faciiiiy fl ll'raccss/1zCcycic ti_7cility ❑ Cl,u_3udriu Site
<br /> EJ I-'\.:°Cusc Vellic!i:. f?umbcr orUt its G fl nzumpsfcrs>`.>q Lu_/r1 —hlum'),L F of Units ❑ i:arnil nct�CEcaoup Sit:
<br /> f'EDiGAL YlAS`p E I'?E:+J—'�'_R.AP::1(L4500) i
<br /> ❑ P`f?n73t j?'�i r: l� t1"f Cifr `'si F+J .4 ��1 il:iCfj t'tUrsin- d_1 x:1.7 rgQ�:�rCn cr7i0r 6.�' St1i'ill'1_::�iCd-,1t0(' ❑ l,tnnfl'Cl H'_'.0 ICF
<br /> U 'l'r�3 nst Cr �+I'-:i i.i,`� `.t�:-III:i;/' ilLit b� 7f liL0a _'.'.cili f"y'. __� ' - li)-- 11 -61) ----❑ NJ(,�ncfJ.tOCS
<br /> FU13U9C 'S, uEFi r pPC+. :At;1(_i16 UU) CCS, r .,7 11) r7U7 ;;rrr_'.lRl,lnairnrr (-�,rnr
<br /> 9_t",iC3Gr=1"tie' 1G-odrVCA"aa0?(FnCii;ilSu'�i>I°jI �`f,l!'!3�OR�r';?"1.''-''`4,'=
<br /> ^l�lvi+T,':(:7 1'1'".1Z IIsi PfI CIIt'.Iti111
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