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GEYERAL PROGRAM FILE New Change Edit (PAOG3) revised 8/76/93 <br /> FiC:4ITT'10 0 FACILITT NAME 4 <br /> 1 � <br /> Lm::CCRD To # PRIOR SWESPSILCM A � <br /> I <br /> DAIRY: Grade A Grade d Milk Dispenser Number of Containers in Mutti-Head Unit <br /> FOOD: Restaurant Maritet Commissary Mobtte Food Produce Stand Iee Piant <br /> Seating Capacity Sp Ft Market w/food Prep: T / A <br /> T-Vorsry Faced Facility _ special Food Event Vending Machines _ Naeber of Vendlne Units <br /> Food Vehicle Make License # Registration Color <br /> HAZARDOUS WASTE: Tons Generated/Tr TIERED PERMIT Fecility CA CE PSR <br /> HOUSING: Hotel/Motel No. of Units Jait/Exempt Institution Nouaing Abeteaeellt <br /> Eavloyee Housing No. of Employees Approx Dates of Oeeupeney / / to <br /> I <br /> LICUtO WASTE: Pumper Vehicle Pumper Tard Chemical. Toilets No. Package Tx Ptant <br /> i <br /> ✓rzoICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Getwator an Conerstor �. <br /> Storage (Z-10) — Storage (I1-say storage ( -ye ) Trader !ta Ltd Hauler _ Vet CLinic <br /> i <br /> 2ECREATIONAL HEALTH- Pool/Spe Number of Pools Out of Service Pool lbturai Bathing Plats <br /> _ SITE MITIGATION: Envirwr Assess USTICAP Lae Max waste Nat MaiC PPL <br /> Other Lead'Ageney Site Agency! RUMICS DTSC MPL Site Ria/Mm 4 Other- <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fac waste Storage Fee Aq Waste/Exempt Site. <br /> Sit Vehicle No- Dumpster Re, Stationary Compactor$its <br /> 4ECTOQ-Ca11TROCr Pouitry-Far Max Number of Suds ICerr+el .. <br /> EMEEGENCr NOTIFTCATIML for thFS:FACILITT. and/or PROGRAM DAr. , >EiGi[i• -._ <br /> CCHTACC r. <br /> CONTACT L C T _ � �. _ e • <br /> OESIGNATer fliP£OTEE A- PROdTA11 ECEiNFN1?tSU r r z l <br /> i#OF UNITS`' EPA1r= AT <br /> Iff<SPECiICNF-GmfiE,�� <br /> BILLING ant=MIPt ANCZ: _. r'. tilt undersigned Q~,Opel COC'Or 006 ei`a:MM-aebgrfeeige Cleat silt ti Ler all 01 <br /> prol-et,Specific PNSlENG hourty chargm associated wtdr- this,facitttr ar•eetfvitr witt:be bitted tai titer putrielatttfie as:tile <br /> BILLING PARTr on. thi&fors. C alsom eartify that E have prepared this appi.icatfom On&thse tlls xeric to.bet performed xf EL bar darw,t` <br /> in accordance with:alt applirabla SAIi-JOIIG)IN COIJITT ordielmcw Codes and/or standards arsf Statae and/or Fedws- [ars..:. <br /> AF'PLICANr'T SIGNATt3tE <br /> Tltte- Date: <br /> ALITHCRIZATION TG RELEASE IMFOR14ATION: In addition to the ab, e, when appiicobte, I, thf owlar.,opWxtOr er eganN of'sow, orf' <br /> the Property located at the above site eddreas hereby authorize the reiaare Of eel)► and•alt reautts, 9eotudinfesL dots wWar <br /> environmentat/site asseswenC informmtieen to SAN JCAGUI% CRAITT mmiji; VALTR SERVICES ElIVIR01611TAL RMTR 011VISI4 as 30o11 as <br /> rt is weiIable and at the same time itk is provided to mss or W representative. <br /> '-e Anmounc ! Aamcunr Paid ! Date of Paywent Payment type Receipt ! Check / Recd BY <br /> k <br /> =nS �� StIPV ��� ACCT _...J l UNIT CLIC <br /> I <br />