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3A IG c2 " 4 1-11-1-1.1 <br /> :c7 RIDDLE'4IACOBSEi,I I_ `_`_._ �P.3,3.u; <br /> C-'NERAL PROGRAM F:LE I New Ch"e <br /> _ ------ (fROG3) ravized Si2al43 <br /> FACILITY 10 * FACILITY NAIME <br /> RECOND i8 # ,J (C73 PRIOR SVlEPSJt Cite Y •`��•. `v_• ,- � <br /> _ OAER;; Grapy A Qrade 8 kick Dispenser — Ntaber of Containers in Nutti-Head Unit <br /> w FLVO: Rcscauran'r karket Carrriasary Ilobite Fold Produce Stand <br /> Seating C�upeeity _ ._ Int Plant <br /> .- ---» Sq Ft ._ Market w/Foch i+tep: Y / N <br /> TerfI�orary Food, Faci(itY Special food Event Y"109lts::hines y�>}er of Vandlnp UriCS <br /> Food VahiGle Hake LICOrkie # Registration >Y <br /> ._._._. Color <br /> HAZARDOUS WASTE: Tonal Generated/Yr TIERED PERMIT raciLity : CA C9 P6it T` <br /> HOLISINC: Note.1/Motet No. of Units j*UiEX*Vt Institution <br /> loyee Housin Housing AbateaMrnt <br /> E <br /> aK' p N0. of EaRt oyoes Approz Oatee of Occupancy �.f. / to / <br /> LIQUID WASTE: purer Vehicle PLNper Yard Chemical Toilet► <br /> go• package Tx Plant <br /> MEOICAL WASTE: Primary Cart Acute Care Skilled N.Jrting Lg Generator <br /> $tor a (2-40 (11-50) . .� Ger)8rator _ <br /> t'9 ) Storoge Storage ( ssp ) irarwtar Sta __ Ltd <br /> 444ler Vet Clinic <br /> UCP.EATIONAL HEALTH: Poot/SPa — NQTber cf Pools Out of Service Pool Natural RaChinq Place <br /> SITE MITIGAYION: j Environ A98e9s _ UV1CAP _ lac Raz ,aste Haz Mat PPL <br /> Cther Lesd Agency Site Agency: R%4C0 OTSC NPL Site a RB/M20 Q Othor <br /> SCUD WASTE: laredfitl Transfer ata Rtcyc"nq ido Waste StOtage FaC _ Ag Waste/EA"t Site <br /> SW Vtnicte ^rte No, ounr�ster _ No. _ Statiav y emiputor site <br /> VECTOR CONTROL: IOWttry Farm ltax Number of girds Kennet <br /> EMERGENCY NOT1FlCATICNi itx this FACILITY end/or PRGGRAH <br /> DAY kIGHT <br /> CONTACY t C,I(j"lfN �IZ(_�f� <br /> CONTACT z l l ,►-� (ANS STE%�. <�. z is �_ �� <br /> a>SIOUATEp iMPLOYEE <br /> 000I _ PROGRAM ELEMENT # CURRENT STATUS <br /> p OF UNITS EPA IO 0: <br /> INSPECTION C00! <br /> BILLING arc! CCNPLIANCP ACKHOWLMp CMENT: 1, the utdersigtied owner, opermtor ar agent of lane aeknowt �--�� <br /> Dralect specific PHS411D hourly charges asaociatea with this faoitity or aetivit wilt Wr bill e44e that all Site aruUor <br /> Y *0 to the party Identified as the <br /> BILLING PARTY pn thlS form. I also certify that I have prepert:d this application and that the work to be parfomoW wilt be dorso <br /> in accordance with alts appticable SAN J0A0L:N C*JUIY ordir 4 ea andl,�r standards and Stats anti/or federal law3. <br /> APPLICA474S SIGNATL2E <br /> 11�2 Date:— 7 �•_ �. <br /> AUTiICRIZATtt)N Tb REL£AsE Yk Rrrat:oN; to iclon to the above, s;ften sEsplicabte, f, the o,rnr, r <br /> the r 4. , operator or agent of sauce, of <br /> p *party located t the above aite address hereby authnrize the retet;se oe any and alt results, g"rechnical O#ta and/or <br /> enviroMlontal/site 3ss;9sflxnt filforvuotiOM to SAN 4CAmILM Cott, TY.PUIILIC NZALT'A SER C91ENVIROr <br /> it is 4v0ilabte and at the same time it i atP�tAL HEALTH OfY1StON as 640n ac <br /> 9 provided Co rmr or my rerprss;entative. <br /> Fee amotr,t Accurst Paid Date of Palment 1>Wmnt Typo Reeeipt is <br /> Chock tt Rtc'Yd By <br /> SUPV _ <br /> _. _1 ACC' IUNIT CLK <br />