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GENERAL PROGRAM FILE New <br /> Change Edit <br /> -- (PROC.S) revised 5/21/93 <br /> FACILITY ED X ll�� ..,_ <br /> FACILITY NA)E <br /> RECORD 10 ! �"7 <br /> (� PRIOR SWEEPS/COMP s <br /> DAIRY: Grede A <br /> Grade a — Milk Dispenaer _— Number of Containers in multi-Mead Unit <br /> FOOD: Restaurant _ Market Ccaalssary_ Mobile Food Produce Stand _ Ice Plant <br /> Seating Capacity . Sp Ft Market w/Food Prep: Y / N <br /> Tamorary Food FactUry __ Special Food Event _ Vending MachinesNumber of Vending Units <br /> Food Vehicle _ Make License f Registration R Color <br /> HAZAROCUS WASTE: Toro Generated/Yr TIERED PERMIT Facility : CA _ CE pgR <br /> — HOUSING: HotelMotel — go. of Units Jail/Exempt Institution Housing Abstmrot <br /> EWtoyce Housing _ No. of Esployees Approk Data of Occupancy �_J_ to <br /> LIQUID WASTE: Raper Vehicle _ Pumer Yard _ Ctwmloal Toilets _ No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care _ Skilled Nun ing Lg Generator _ Sm Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) _ Transfer Ste _ Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Hurber of Pools Out of Service Pool _ Natural Bathing Place <br /> ✓ SITE MITIGATION: Environ Assess _ UST/CAP V lac Naz Waste _ max Mac PPL <br /> Other Lead Agency Site _ Agen y: RWQC3 _ OTSC _ NPL Site _ RB/H20 Q _ Other <br /> _ SOLID WASTE: Landf 111 Transfer Sta _ Recycling Fee _ Waste Storage Fee _ Ag Waste/Exeopt Site <br /> SY Vehicle _ No. DLP ter __ No. Stats arory Coapector Site _ <br /> Ir) <br /> VECTOR CONTROL: Poultry Fare_ Ux Number of girds - Kenai — <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAT Vicar <br /> CONTACT t : BOB YOUNG — GENERAL MANAGER 1209 ) 477 . 8896 X09 957 3615 <br /> CONTACT 2 . NANCY UAHLIN (209 ) 477 . 8896 (209 )951 -944/4 <br /> . <br /> OESIGNAIFD EMPLOYEE ? PRO <br /> CURRENY STATUSPRO" ELEME)11 ! <br /> Y OF UNITS EPA !D S• INSPECTION CODE <br /> BILLING and COMPLIANCE AOOKULEOGEMENT: I, the undersigned awror, operator or egert of sem, acYx+owledge chat all site m"VOr <br /> proieet Speclf is PHS/EHD hourly charges associated with this fact Lity w activity will be billed to the Party ldentif led as the <br /> ve prepared this application, ed that the work to be performed will be done <br /> BILLING PART? an this fore. I also unify CMC [ ne <br /> or Federal laws- <br /> in accordance with all applicable SAN 10AQUIN COUNTT rdttetce Codes and/or Standards and State and/ <br /> APPLICANT'S SIGNATURE : <br /> Title: D�'f77f�g'i _ Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above. +hen appllrahle, I, the owror, operator or' agent of same, of <br /> the property Located at the shave sits address hereby authorize the release of sty ad all rewlts, Beotachni=L data and/or <br /> emiroraental/site assessment information to SAN jo"IN COUg" MMIC HEALTH SERVICES ENVIROMENTAL HEALID DIVISION a, soon as <br /> it is available and at the saes tiler It is provided to me or my representative. <br /> Fee Arrant AooVrt Paid Date of Payment <br /> Payment Type Receipt s Check ! Rwvd BY <br /> AENS <br /> ACCT /-� UNIT CLU' ���-- <br />