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FACILITY 10 : FACILITY71A-W412tit/c <br /> R£CCRD 10 # PRIOR Si rXi"S/COKP <br /> DALRT: Grade A Gride a Milk 01Apen4er mer of Containers in Mutti•Read Unit <br /> FOM., Restaurant Market Coaaissary Kobito Food ProdiGe St" Ice Ptant <br /> Seatirq Oapaeity . Sq Ft Market w/Food Prep: Y l N <br /> terporary Food Facility Speeiat Food Event verYiirw Nachirw!s Number of YtMing Units <br /> Food Vehicte Hake License # Registration # Goior �r <br /> HAZARDOUS WASTE: tons Gereerated/Tr TIERED PERMIT Facility ; CA CE pelt <br /> HQUS1uG: Hotet/Kotat No. of Units deit/Sxemppt institution Hmming Abat=irnt <br /> lsmployee Housing No. of EAVtoyets Approx Oates of O:ctipa(xy �f_J to —I—� <br /> LtvUib WASTE: Pi=per Vehicle Pu pwr Yard Chaalcal Toi tats Yo, Pac'ts$e TX Piant <br /> MEDICAL WASTE: PrIcmary Gare Acute Cart Skilled Ntssirp Lg Generator Sm Generator <br /> Stnrage (2-10) Storage C11-50) Storage C s50 ) Transler Ste Ltd Hsuter _ _ Vat Ctiiiie <br /> �_�R£CR£a?(ORAL HEALTH: Poot/Spa ` )ILSber of Posts � Out of Service Poo( Natural &ath(ng Place <br /> fr <br /> ! SITE MITIGATICN: Environss <br /> Aess �/ int/CI,P Loc HEL Warta H42 Nat PPL <br /> Other Lead ACmcy Site Agency: 214CS 0T= NAL Site 29/H29 4 Otho <br /> SOCIO WASTE: Lardfill Transfer Sts Recycling Fac Paste Storage P*c _ Ag %4nte/EXompt Site <br /> SU Vehicle No. Otsptter No. i <br /> VECtOI CONTROL: Pouttry Forma Max Waber of Suds `IVED <br /> E.NX-RGEHCT ROTIFICATIOit for this FACILITY and/or PROGRAM DAY 91W(T <br /> Philip Metzger ENVIRONMENTAL HEALTH <br /> CONTACT t P g (510 ) 942- 8?" <br /> MIT/*- ERVIrms <br /> CONTACT i . Philip Miller ( 714) 553 - 8757 ( ) <br /> OESIGXATtOEI1PtJTE$ # �� PROF; M ELET:E31T # 2 1� So =$rO STATUS <br /> 'l—1.1 <br /> it OF UNITS : EPA 10 k IKSK(:TIC$t CME <br /> IMLING orb CnottAXCE ACSDtCULEDGM(T: 1, the uhdlrsigned owner, operator or event of sear, actvw(ed?e that all site acxf/or <br /> project specific Pmts/EHO tm«,rty dser9es associated with this faetEity or activity will be bitted to the party identifi as <br /> B(LLtNG PARTY on this fors. I also certify that t have prepared this m+pplicatiorr and that the wdrt to be pe t be do <br /> in accordame with alt appiicable ECW" cod" ardor Stard3rds and State sand/ <br /> c APPLICANT'S SIGXATUR£ : <br /> Title: Project Manager Otte! March 20, 1995 <br /> AtiTNCRrzAT1CY TO RE1�� tNFCWTtO9: In addition t4 the above, when apptiCsble, i. the carer, Me( for or agent of sroe, of <br /> the property Located at the above site addr*" hereby acrthmstitt the retono of any and At results, peoteum(cat data wirVar <br /> errvirenaentallsite assessment infer altfen to SAIF 10=19 aIW" PUSLLC AEALTH =VTC S ENViR0(A(WAL Hi:AI.TN 01VISIaN as vxn <br /> it is avvilable and at the same tiw it is provided to me or my representative. <br /> 94* Amount AmmAle Paid Otte of Payment Pey-cmt Type Receipt t Check R Recvcf Ry <br /> J' U%IT CLX <br /> 3/Z7 <br /> /.k <br />