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b[OtRAL "OCRAM FIL! I Nhw ChangeEdit <br /> T„ -- ��...r_ (PROG3) rtvistd 5/18/43 <br /> FACItIT? to 0 FACILITY NAME <br /> FRIUN SWEEPS/Comp a <br /> AAttlY 019dr A Qrpde Et Milk Dispenser Number of Containers in Multi-Head Unit <br /> =1 . 'Rttburarit Market r_ Commissary Moblter FvW _ Produce Stand toe dont <br /> =Fb1i_tthl tawlty _ Sq Ft Market w/Food Prep: Y / N Number of VoWirto Mechines <br /> /OOd YsAfatt' !lake License N Registration ti Color �~ <br /> ,ON& tlAtAllM UAPP Tons Generated/Yr _ tIERED PERMIT Facility CA CE PBR <br /> as;_, HOUSINat Hotel/Motel No. of units Jail/Exempt Institution <br /> ilepleyte Mousing No. of Caployees Approx Oates of Occupancy _/ / to <br /> LIQUID WAITts PV" P Vehlete Pwmper Yard Chemical Toilets No. Package TX Plant <br /> D[irlll WASTE: Primary Cara Acute Care Skilled Nursing ! Lg Generator Snl Generator <br /> 2torege (2-10) ,..� Storage (11-50) _ Storage ( >50 ) Transfer Sts _ Ltd Mauler _ Vet Clinic _ <br /> t `y. RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of service Pool Natural Sathing Place <br /> ' Si IE MITIGATION: Environ Assess UST/CAP t� Lot Hat waste Na: Mat PPL <br /> Other Lead Agency Sita Agency: RWOC2 DTSC _ NPL Site RS/H20 G -, Other <br /> Y _ latio WARTRt Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> Sw Vehicle , NO. Dumpster No. statt00%ory cw"etor site - <br /> VECTOR CONTROL: Poultry Form Max Nundjer ur elyds konnot <br /> EMERGCNCY NOTIFICATION for Chic FACILITY an�dJ/or 100RAN DAY -u� NICHT <br /> CONTACT 1 : _:j Ch��U`'��-O IIJV-c�� (31U ) -_�� ..._ (310 )�1.5� - 17b-3 <br /> 1:oNtact 2 . TT A-- 4Y - Gs 137DESIGNATED EMPLOYEE A PROGRAM ELEMENT N CURRENT STAtUS <br /> 0 OF UNITS : EPA 10 01, INSPECTION CODE t <br /> IILLiNO ACKNOWLEOdEMENTt 1, the undersigned owner, operator or agent of same, acknowledge that bit site and/or protect specific <br /> PHS/litD hourly charges associated with this 60,11ty or activity wilt be bitted to the Party idtntifitn tis tier aILUN4 *A>ttr eK— ' <br /> this form. <br /> I also certify that I have prepared this application and that the work to be rfareied wilt be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes nd Standards, State and FederLOX," <br /> aNs. <br /> APPLICANt's StGNAIURE <br /> Titte• H,-v Date: J <br /> AUTHORIZATION TO RELEASE FORliA7I0N: In addition to the above, when applies le, I, the owner, operator or agent of same, of <br /> the property located at the above We address hereby authority the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISICN as soon as <br /> it is available and at the saim tient it is provided to me or my repreeantAtive. <br /> Fee Amount Amount Paid oats of Payment Payment Type Receipt N Check M Recvd By <br /> RENS J..--J SUPV / 1� <br /> ACCT ___ <br /> i'0'cl t'TezT0t*0TCT 0i `„ 140�1d 1JJ2T:b0 C66T-92—rQ <br />