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NOV- 18-98 01 : 11P . P . 02 <br /> GENERAL PROGRAM FILE : Na Changr Edlt (PROG3) revised 5/21/93 <br /> FACILITY 10 Y FACILITY NAME <br /> RECCRC IO Y MLIOR SLEEPS/NIP Y <br /> _ DAIRY: GrOde A Grade a _ Milk Oiaoenaer Nuaber of Containers in Multi-Head Unit <br /> FOOD: Restaurant _ Market _ Cornissary _ Mobilo Food Produce Stand Ice Plant <br /> Seating Capacity Sy Ft Market w/Food Prep: T / M <br /> Teaporary Food Facility __ Special Food Event _ Vending .Machines au:ber of Vend Tng Units <br /> Food Vehicle _ Make License Y Registration t Color <br /> HAZAACa13 WASTE: Tom Gerxnted/yr TIERED PERMIT Facility : CA CE PBR <br /> KDJSING: Note(/Mate( _ No. of Units :AIVEAehpt Institution Housing Abatement <br /> Employee Housing _ No. of Employees AWGX Oates of OCLUpWXy to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chaaieal Toilets go. Package TA Plant <br /> MEDICAL WASTE: Primary Care , Acute Care Skilted N:.rsing Lg Generator _ Sm Generator _ <br /> Storage (2.10) _ Storage (11-'.0) _ Storage f >50 ) Transfer Ste Ltd Hauler '/et Clinic <br /> RECREA C ONAL HEALTH: Poo LlSpa Nurber of Pools Out of Service Pool _ Natural Bashing Piece _ <br /> :17E MI'IGAT!ON: Environ Assess UST/CAP Lx Mat Waste Naz Mat PPL _ <br /> Other Lead Agency Site _ Agency: R(ACB OTSC _ NFL Site RSJH2O 0 Other <br /> SOLID WASTE: Landfill _ Transfer Sia _ Recycling Fac Waste Storage Fac _ Ag Waste/Exempt Site <br /> SL Vehicle No. Cuapateir No. Stationary Compectar Site <br /> VECTOR CCNTRCL: Poultry Fern _ MAK Nutber of Birds Kernel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM OAT NIGHT <br /> CONTACT 1 1zi ' < ',&l) AL1 Sy�J� <br /> CONTACT 2 : u (�� /c c ( 1 's2� • fy ( ) 9a1'- 'v L <br /> DESIGNATED EMPLOYEE Y PROGRAM ELEMENT 10 SO CJRREMT STATUS <br /> a OF UNITS EPA 10 e: INSPECTION =E : <br /> BILLING and COMPLIANCE ACKHCNLEDGEMENT: 1, the urdermfgned owner, cperatbr or agent of same, acknowledge that all site and/or <br /> project specific PNS/ERO hourly charges associated with this facility or activity wilt be billed to the party identified as the <br /> BILLING PARTY on this torn. 1 also certify that I have prepared this appliWtlon and :hat the work to be performed will be done <br /> in eccerdance with all 3pc0cable,SAN )CAMJIN COUNTY Crdirance Codes and/or Statderes and State and/or Federal laws. <br /> e <br /> APPLICANT'S SIGNATURE <br /> Title: LM 'ti?i �/` Oat.. <br /> AUTHCRIZATICN TO RELEASE INFCRMATION: In addition to the above, when app:icabie, I, the diner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and alt results, geatechnicst data and/or <br /> envircmmitaL/site assessnert `nformation to SAN JCAOUIN 'C"TT PUBLIC HEALTH SERVICES ERVIRCNMCNTAL HEALTH OI'/ISICN as soon as <br /> it is available and at the jam tier it is provided to me or my representative. <br /> Fee Anand Amount Peid Date of Payment Payment Type Receipt Y i Check a Recvd ay <br /> RE3S �I /�/� SUPV _/�_ I ACCT _!_/_ UNIT LK _/�F_ <br />