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<br /> GENERAL PROGRAM FILE ° '���` Neit
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<br /> FACILITY ib 1-•. �` �xy
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<br /> RECORD ID #, t PR[Olt '
<br /> -�<-,.f r ,t, SWEEPS/
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<br /> DA[RY r Grade A- E Grade B Mi l k D is ensss Wow'� '
<br /> r , _ p Mudie oat'Cantairtersfn Mul - esa. { ti �;
<br /> _ FOOD Restaur nt ��'��Market Commissar Mobi a Foody r 7= Prodiie t
<br /> rW .l 1 s 'F a $t 1 Ice-Pant' r
<br /> ` r } SeatiragCapacityS Sq Ft.; '• `` `}larket�w/Food Prep_ °F
<br /> ,{ ,+ [, "r s..r- •F"- ,".r rr at F c t - ,,V;•,Tkl A-..
<br /> r rk TemporaFOod Feclllty. - ��`�c S1Y.�w-..-iaC Food-Event;'
<br /> 1•,"� ,.. .� d __ -, ..;.,ti ^ 3 • cy ..:�. h , ,r y Yendtng.Flachines` -� �,Munbe of Vend tJnits�s s +Y
<br /> a- FQQd Vel?te[e , if s4 :e'
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<br /> : License . Registration # `*,Ulal
<br /> a� ? ;, �''�T�S.• +7ti r. I!-r - 'rat '" ,:� D i �TIERED PERMIT�Favifity .CJ4, � �d }��-;.4 ,�yxr .a .:r.,, j .
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<br /> 9 r Ys9k',_ .�3�.�52 -+7ti- a L Irl" rr•µ' o� �., .2.11`. y`' .�1 �•r
<br /> ^��HWSiNG}Y �Yrt rHote[/Mote dr NOrrof Units f ei[/EXM1 sIt�atoil f' rig-
<br /> yds mP ! Aper x Dates Abataemert
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<br /> Errptoyee Housing,x yi+Nn of E tk ees' { 7� !} V� 4 ► Y'
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<br /> "@�, :t''yg ;Vn ' i '= y"A , � �
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<br /> LIQUID WAkS�TESJ Pompe Yehtc[e x Pea!!>per Yard 'ChemicaUldlLets y No r "SPacke9e Tx PCant�
<br /> 1 R 1 �.� S •-t1 Gi' ]' - - �'�('- _ L '� -j•
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<br /> MEDICAL WAST ,: l T 4
<br /> E Prtmar Care' L �"
<br /> sky, "Acute Gare Ski[[ed Nursing "� g GeneGenergtar
<br /> `Storage (2 i0)._ ElStvrage lit 507; Storage C >50~}Y{. �r 7e"anafer Sts' . Ltd L : 'u
<br /> FSAp, ta,-,srf�l;ra ,..i,. ,.•. ck3TSE 3 { F,.HaU er':—��' �Vet Clinic_
<br /> •-.,,1,,y� a'f^', s vj 1. i -s.�o<k nxr _qjs.� ,,''+�iy }� .
<br /> �;`k '> S'a�.. ,! �;t- } •'{,d.: 3S' ' 1 gra;,^y h�
<br /> RECREATIONAL HEALTH s s PooC/Spa + Nuar36er of PQa[s� i'� rNf-fl „” fi {
<br /> _p out of Service.Pool Natural Bathirlp.Ptace
<br /> r7. r e]: �7Gy^' 7'77.: .'�+a�,
<br /> �,S �''e. -'�," >3;,1 �''5.,,I r• •.� ',{�,I ate, ` Iln �77,,'•rr" ' Y 'i, ;F
<br /> r .. kd•- ' y i; !!',...M V1'�.,,:_. -1 �.) i1 1�M.�•,ti. S
<br /> SITE MITIGATION Envtr
<br /> on Assess ; USF/CAP LQr�.Hex_Wasta c'r r Nez Mat PPL iS „
<br /> Other Leed A ene Site x " fit Irl f NRg HZ77 Q'� k 7
<br /> a 9 Y Ager►cy� RWQCB �aF^ DTSr NPLkSitr / r= ether ,
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<br /> SOLID uASTE Landfl[[�f>"" ''` Transfer Ste ` Recycling FaceLZ
<br /> Waste Stora Fac � ;Y " d >ka� •'
<br /> --- geAq Waste/Exempt_Site .
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<br /> 5W11�aVehtcleNa,} uDu7rpsterr NQ ' f� Stationary Caipector SitaJ�
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<br /> • 1 '+.i`y r�7- fi'rt'7'c. 'a M6 004,
<br /> VECTOR`CONTROL 1•r_,Poultr Farm11�Sr.ti.ata
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<br /> EMERGENCY NOTIFICATION for-this..FACICITr,aiiWor PROGRAM i° k` ' f s➢; DAYf `„e` d r. ;y� ,�r Y ° #
<br /> CONTACT
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<br /> ryCONTACT,+�1i:,
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<br /> DESIGNATED EMPLOYEE'#; rJ. " pZ PROGRAM ELEMENT sr�
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<br /> IRi pF UNITS S�° � ' �P'+� EPA.IDS#��a"E>��F��'�"`�u��� •�o-xa f� ?t� �".yw-�y>-.v= w�ri� . M11 u- ,�f
<br /> Ml�hwdr, ),�„ aNvy:'r
<br /> 111lLING ani CONPLIANCEbACKN011LEDGEMt 1iT i�e`°undersi; � ' � `
<br /> , a a , fined awneip operator or agent'af'saw ackMWL Lha aE eat atiand[ w.
<br /> project specific PH5/EHD of f C lahget es ocieteci`vith'th��f ci: [ a x g ' r� u Nip, �.'�r
<br /> Y �; - , R�N•� � y... Y L ty�6r�setef ter x3 tt:be bitted' o th'e party Menti, ed.
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<br /> F BILLING`PARTI- ;thf farm atao.certf %thet r have prepared.this"appucatiortard;-that,ttte ware be rfoIQ Inaed���"
<br /> ' in atrardante.Wlth [�. a Lie8a -- ,11f n{,7 .. Y9c n,��.. ,d, -.,F „_r a R Fli..•r ye /^;:l -
<br /> n pp . Le�5AN JOAQUr COUNTY Ordinance Codes artd/onStaridartis and State
<br /> armor Faders leue-
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<br /> .�' '1,s:�`�> "��`4 �rart ny>��': ,�,.� " �'�{a� -ra z` a9 '• i a.� �� � � ..
<br /> APPLICANT'S, SIGNATURE
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<br /> ` AUTWRi ON TO'RELEASF�INFORMATIpN:� Irf eddttion-toFthe above, eiVapp icabI ithe nwrler oper`stoara r agsnC ofgsame, of
<br /> the prnperty'[ocated�atithe a6ave site address herebyry authorize the releese'af''arly arte�:'alt^reslllt�k
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<br /> env irernentaL%site assessment. tnfarmation to SAN`JOl{QIIIA COUNTY PUBLIC HEALTH SERVICES"ENVIROf�NYAk iIE1I�T!!�D>tYI5I014 sa,soorl:as�r '.
<br /> K`it is 0+iaa[ebCe:'erd�at{theTsame timer it is-provided to me or my representative ,c"ray
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<br /> Fee Amount �-Amount Pald r Da "' ' YW Y '
<br /> y + Fte Qf.PaYmerrt. Peynlerlt Type Receipt S' x Check 4 Re
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<br /> REHS ACCT wl,i,` UNIT
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