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�. 12/10/97 08:19 BLACK & VEATCH <br /> N0.989 D03 <br /> CEHERAL PROGRAMFIL! T Ne+ ` ClEenpe Edit tPR0t13) revised 5/24/93 <br /> FACLLIY>r"IO 1 FACILITY MARE <br /> RECORD 10 I PRIOR S4P.EP5/COMP 0 <br /> DAIRY: Orsde A ,_ .rade O Milk Dispat,ger NUriber of Cattslttere In multi-Head Unfit <br /> Cortm;S§At% Mobile rood Produce Stand Ice Plant W� <br /> ft7ODe Restaurant Market y <br /> —� Castlnp Capacity Sq Ft Hnrkat w/ro*4 Prepi ' N <br /> tai Food Ev�!nt Vend!„R Haahlnss Mtn-bar or Yendlr,p Unita _ <br /> Temporary food Facility Spec Cater .., <br /> Food vehicle Rake Lieenae +T <br /> I <br /> HAZAROCUS WASTESTorts Generated/Yr <br /> TIERED PFRnIT Facility CA CE PBR <br /> HaUSiMGt Hotel/Motel No. of Lhtttg .salt/Eiffmt institution Housing Abetemenit <br /> Employee Nausirg No. of ErtployeeR AMrom Dates of occupancy to <br /> r Ystd� CGcnicaf`tolt4tr ''” 'Ise: �"` -Package Tit-Plant w T <br /> "LlaVtt)'uA81Et '> r.Y-hIata,,..,t_. •P ..- A_ - <br /> MSOICAL WASIEi Prlrary Cara Acute Care _ _ SkIIted"NursIng Lg Generstor Sm Generator <br /> Storage (2-10) storagett1 50) _^ Stornge S X50 ) __ Iranffor:S to Ltd llauter T Yat Ctinla <br /> RECREATIONAL HEALTH: Poot/spa Nudger of Poots Out of service Pvot Natural Bathing Placa <br /> SITE MITIGATIONS Environ AsseRs __X USr/CAP for Aaz U09te liar: Nat PPL <br /> Other Leed Agency Site Agency. RtOCR DIST 'X _ NPL Site RSIM2O Q Other <br /> SOLID WASTE: Landfill Transfer Sts Recycling Tac Wn%te storage rac Ag Waste/E><empt Site <br /> SN Vahicte He. No- Stationary Ca motor Site <br /> E <br /> VECTOR CONIROL: Poultry Farm kms H+�•--r of 81rd4 kerr►el <br /> DAYS?r� NIGHT <br /> EMERGENCY NOTIFICATION far this FACILITY and/gr PROGRAM UJeh,5,�� <br /> CONTACT 1 'I Ron Palrnquist t 209) 937 - 8538 : f 209) 937 - 8320 <br /> CONTACT 2 s Garrett TQy _ t 209) 937 - 8538 t 209) 937 8075 <br /> DEN GMATEO IMPLOTEE S PROLRAN £t-EMENT A CURRENT ST47UC <br /> t EPA ID AS <br /> INSPECTION CODE <br /> _ ri <br />�- <br /> BILLING and GUMPCIANCE ACKNOWLEDGEMENT: i, the undersigned miner, operator or agent of amm, acknowledge that sit site and/or <br /> project specific PNS/EHD hourly chargee associated with this faculty or activity will be bitted to the party Idantlfled as the <br /> PARTY on tthis form. t also certify that 1 have prepared this application and that the work to ba Performed wilt ba done <br /> BILIiNG <br />+ In aceordance with alt applicable SAN JOROUIM COUHTT ordinance Codes and/ar 5t"*rds and State end/or Federal taws. <br /> ADpCICAHTrS SIGNATURE ] <br /> 0 <br /> Page <br /> Title] Deputy Director/R vela meat Oste: 1 as 1 f113 <br /> AUTN4R1ZATi1W TO RELEASta. INFORNAT[ONs In addition to the above, when applicable, 1, the 9lmr, aparater'or agent of sane, of <br /> the propmrty`toem,Od at the abvva site address hereby suthorize the'retease of any and all results, geatechnicat date end/or <br /> envlrormental/alta assessment information to SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES EHYIRommWAL HEALTH DIVISION as goon as <br /> it is .reliable and at the same ti I t is provided to mea or my representative_ <br /> Recvd ay <br /> fee Amount AmouAmount Paid Oita of Parnent payment Type Receipt Y Check R <br /> REBS SUPYACCT! �I _�l UNiY CLK;e <br />