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GENERAL PROGRAM FILE I New Chw.rge Edit (PRW) revised 5/21/97 <br /> FACILITY 10 ! 'II!- I FACILITY NA)[ <br /> RECORD 10 / DUO L PRIOR SWEEPS/COV <br /> DAIRTs 0rsda A __ CFO& I Milk Dlepenstr Ntarber of Co,talrwirs In Multi-Mead Alt <br /> Fowl Easteurent _ Market Caralas.ry Kohl(* rood Produce Stand Ice Plant <br /> ie.tireg Capacity SQ Ft __ M.rk,t ./food Prep: Y / N <br /> Tmporary Food Facility_ Special Food Event Verdlrq Machines _ Timber of Veidlro Unita <br /> FOOD Vehlet• _ Make Lle"e I _ Registratlai I Calor <br /> HAZAAOOUS WASIEt Taro Genersteclm TIERED PERMIT Fat 111ty I CA _ CE _ PSR <br /> MOUSINGI Hotel/Mott,L _ No. of Units Jail/Exeopt Institution _ Housing Abetment <br /> Enployte RousRM _ NO. of Eaptayeas Arrrox Dates of OCct{wey _/ /_ to —f—J— <br /> LIQUID WASIEI Meat Vehicle POiper yard CheIeleal Toilets No. ►.clop, T. Plant _ <br /> MEDICAL WASTE: Primary Care ^ Acute Care Skilled Nursing Li; Ceneretor _ Sm Generator _ <br /> Storage (2.10) _ Storage (Ii-SO) _ Storage ( ,SD ) honorer Ste _ Ltd Hauler _ Vat Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa HuTher of Pools Out of Service Pool _ Natural lathing Place <br /> ' SITE MITIGATION: Envlral A sets UST/UP Loc Hat Waste _ Met Met PPL _ <br /> 1 Other lead Agency Site Agency! RWOCR DISC NPL Site _ A11/920 0 _ Other <br /> _ SOLID WASTE: Larr1(Ill Transfer Ste _ Recycling fee Waste Storage Fee _ A9 Wss[e/Exmrt site <br /> SW Vehicle _ No. DtlT ter so. Stationary Cm;ector Site _ <br /> i <br /> VECTOR CONTROL, PaWtry Tom _ Max Nurbr of girds Kerr,eI <br /> EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAM Oa[ NIGHT <br /> CONTACT 1's N o rl <br /> CONTACT 2 S <br /> DESIGNATED EMPLOYEE I PAOGRAM ELEMENT S Q V C� CURRENT SIAM <br /> I OF UNITS t EPA 10 /: INSPECTION CODE <br /> SILLINO and COMPLIANCE ACKNOYLEDGEMENTI 1, the Vderslgned owner, operator or agent of Rate, acknowledge that ell site end/or <br /> project specific PMS/EMD hourly chargee associated with this facItIty or activity will be billed to the party Identified as the <br /> SIUIMO PARTY on this fora. I also W iffy that 1 w spared this appllution and ae <br /> that the work to be perfard will be dor,* <br /> in aceordanoe with sit aipl JOROUIN ST irome Codes W/or Standards end State and/or Federal taus. <br /> 17 <br /> �APPLICANT1IGMAT RE I <br /> �iltle: D tet Peg 1011 <br /> AUTHORIZATION TO RELEASE INi RATION, In addition t the above, when appI!cable, 1, the owner, operator Or agent of sores, of <br /> The property located at the above site address hereby murhorlxe the retest# of any end all results, 9totechnfeet data and/or <br /> anrirart.entat/slta aetessaeat lnfonotion to SAN JDAou1N LL71Nty PUSLIC HEALTH SERVICES ENVIROWCWTAL HEALTH DIVISION as soon as <br /> it Is @,*liable and at the saes taus it Is provided to ae or my representative. <br /> Fee Assam Mont Paid Data of Payment Psyrnan[ Type Recd lPt I [hoot / Ascvd Iy <br /> D <br /> RENS _/_/_ SIPV _/_/_ ACCI !X/ / LIMIT CLE <br /> • 1 N 0-7 1 <br />