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rEHEPAL PROGRAM FILE : <br /> FACILITY ip I ---- Chebge <br /> -----_ — Ed! <br /> RECORD <br /> ID 0 iO2 - FACILITY NAME - (PROG3 <br /> I` �S�/? D ) reviled 5/21/93 <br /> DAIRY' Grade A /c01P PRIOR stTePS -- <br /> �_ Crede g --- 'F <br /> — FOOD, �_ Milk DlnFxneer <br /> Restaurant --_— <br /> —�. Httrb„r <br /> SootingeF Gonial e ! - <br /> Mrxr, ` <br /> It"4torer COpacityarkot Commiseer n Mul'(•Need_ (Ail.' <br /> Foody Food Facllit~- Sq Ft y Nablle <br /> F <br /> Vehicle Make y Speclnl FoodvE ,n Market u/Fo p,en Pro,k,e Stand <br /> Verylr Y / -� Ice PI not <br /> HAZARD —�- Lleensa N 9 Machines A <br /> OUS WASTE: __.__ —_ Req le tre Nurber of Vendin <br /> - "I Cenereted/Tr tfoi M 0 Unite <br /> HOUSINGINote(/Notal --- TIERED pFRtt1Y F _-- Color — <br /> Employee Housing No- of Units ecllfty : CA ----- <br /> No, Of Employees -� CE FOR <br /> LIOU -- Jall/Exerrp[ Inetf tutfon <br /> 10 WASTE' Ptsnper Vehicle -- Af3'rox Dates of Occupancy - ^- Iloasing Abatement <br /> Pumper Yard �/,/I to <br /> Primary �- <br /> MEDICAL WASTE; rhemlcel Foliate --�--�1 <br /> nlery Cere � No, '--- <br /> Storage (2-10) Acute Care Package Tx plant <br /> Storage (11-50) Skilled Nur.Ing <br /> StoreBe ( >Sij Lg Generator <br /> RECREATIONAL HEALTH: Pool/S� --- Fronafar ste Sm Generator _ <br /> v Nudger of pools Ltd Hauler Vet Clinfe <br /> -4 511E NITIGATIOI: Out o/ service pool <br /> Envirm Assess Natural Bat <br /> Other Lead Agency Site UST/CAP hing Place <br /> Agency: RWaCRLoc Nai Waste '-- <br /> Al Disc Nat Net PPL <br /> _ SOLID WASTE: landfill --'--T NPL site <br /> Transfer stn RB/H2O O �_ other <br /> SW Vehicle Recyclingne F --- <br /> No. 0maWaste Storage Tec <br /> ' ter No, A O New to/Ex arm[ Site _ <br /> VECTOR CONTROL: Paul try Term Nnx N Stationary COOpactor Site <br /> r^ber of Birds --- <br /> EMERGENCY NOTIFICATION - -- Kenn@I <br /> for this "ACf ilT- Elxi/or PROGRAM <br /> IT- <br /> + DAY ---_ <br /> CONTACT 1 I r3 Pt9t'r?e- r-t'11',•LL r NIGHT <br /> CONTACT 2 t r.U t._ _ t I c.,.I (--1)!L�- u/ <br /> DESIGNATED EMPLOYEE / PROGRAM ELEMENT 0 c / y 3 r - ,— <br /> 101) CURRENT STATUS <br /> S Of UNITS : EPA ID S! <br /> INSPECTION CODE 6 <br /> BILLING erd COMPLIANCE ACKNOWLEDGEMENT: the Myers lgned owner <br /> operator <br /> pro)ect specific PHS/EHD hourly charges. elated with this facility Oractivity will ofSame,enrol act to teeJpe that ell site end/th <br /> BILLING PARTY on this form. I also certihat 1 hove prepared this application and that billed to <br /> no the party Identified*11 as the <br /> or <br /> In accordance with ell applicable SAN JOA COUNTY Ordlnnnce Codes. ery/or sterdnrds end state ar work <br /> be performed will be done <br /> APPLICANT'S SIGNATURE _(/.f l[' t, ya Federal laws. <br /> ,4.1� <br /> Title: T e' /�(1211am, �f )ate! <br /> AUTHORIZATION TO RELEASE INFORMATION: htim to the e /, /'(7k[' ///// <br /> the prenerty located at he above site a hereby authorlte,the release carne, 1, the owner, Operator or agent of same, Of <br /> t, <br /> envlrormenUl/site assessment InformaticAN JOAOUIN COUNTY PUBLIC HEALTH SERYfCnd all results, geotechnteal date anal/or <br /> It Is vallable and at the same time It vided to me or ENVIRONMENTAL HEALTH DIVISION es <br /> s.0' representative. soon an <br /> Fee Amant Amount Paid a of Payment Payment ) P - _ <br /> type Receipt / Check R <br /> Recvd By <br /> REHS f_--/— APV /-- / ACCT <br /> 777 , <br /> _ ---supe UNIT CLK <br />