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i, Tuesday October 4 , 1994 - <br /> 10-04-1994 05 : 04PM FRO /- TO 19169200463 P . 03 <br /> % GENERAL PROGRAM FILF : 6 New ✓ Cnango Edit Lrautia rntaed 5/21/93 <br /> I ' I <br /> FAULln 1D 7 i FACILITT NATE <br /> 1Tq Or <br /> RECORD ID 2 PRIOR SwTJEPi c" ! <br /> OAI " ev trade A trade B milk Ditperrar , suzbor of Containers In Hutt IANad wit <br /> row: Rasteun-x It Merkur Corolssery _ wobl to Foo! Preduce Stand _, in Plant �. <br /> Seating Caped ty Sq Ft wKkat WFood Prep: T / w <br /> TesT>wary F Facility Special Food Event Y"Irli wuhlnes Ndsbor of Verding Uolts t, <br /> food Yehicle wake License ! Registration i Cola' <br /> I <br /> RAIAR=!9 UWE: I Tor ceneratednr TIERED PERMIT Fac( tlty ; CA _ Ce � PINT <br /> HOUSING: Nottl/woteI _ No, of Units Jai Lifxempt Inatitvitlw wousing Abetment r <br /> paplayea HonirpTIIII � No. of Emloyees Awax oaten of Ottuparwy to <br /> _ LIOUIO OAATE : ar+'pr vehicle Proper Tard Cbwwinl Toilets _ No. Packs" Is Plant <br /> WO [CAL TASTE: bHoary Care _ Acura Car@ _ Skilled atralng Le Cirrretdr S4 Gd+erator <br /> Storage (2-tO) �,•_ Storage ( 11-50) Storage ( v50 ) Trerrfer Sto lid Mauler �. Wt Clinic �. <br /> _ RECREATIONAL HE Hs Pool /" _ wlnber of Pool! <br /> Out of SafvlGe Pool NaiVTsl Nathlrq Plat[ <br /> SITE MITIGATIONt Er irW Assess ✓ UST/rAP Loc Nsi Wate _ Hsi Net PPL _ <br /> ~_ other Lend Ager SIt* A0trCY2 RUX3 �✓ DTSC vt Site RD/a20 O 011ier <br /> E' <br /> _ <br /> MUD TASTE ; L flit _ rrmfar Sts Recyclfno Fee <br /> _ Yssta Stacage F.e M) wstuEt.apt lice [: <br /> -Su vel lel* Mo_ T^ Duspaeer So. Stationary Compo Site �^ <br /> VECTOR CONTROL: I Poultry Fare wont wu if r of Blids Icerwl <br /> EHERGENCT HOTIFI; T19 for this fACILIn0 � ® DAT NICar <br /> - CONTACT 1 (�) <br /> CONTACT 2 . <br /> DESIGNATEDEfrWTE ! a� Z l'ROL7tAM EIfl�IIT At 'L tSF11ENT st11((RC p <br /> NOF UNITS • ^. EPA ID to INSPECTION CWE ' <br /> or <br /> BILLING and cawvL[Aw AGJN%N.EDGElIENT: i , the undersigned orrr, aperaoor Or organ[ Of rase, atldnowletlge that <br /> all. site and/ <br /> project specific vo haorly Charges a fared with this facility or activity wilt be bitted to the Part fdantifled as the C <br /> BILLING PARIT on thiLrLr fare. t atao certify that t hex+ prraerad this appLTdtlon and due rite perk to lr parfottMd w{ Ll be dory �. <br />.. accardswe with t apptl SAN J00=10 OXWY 1 xww Semdertle and Slats and/or Tderal laws_ <br /> y` APPLICANT'S S1PrA <br /> Title :. �co ect k� Q4re CHam HILL aster <br /> AUTIIONIZATRELlEASC Iw TION: In addition m the abowa, wbonl applfiable, 1 , ews orar ar d'. operator- agent of ecce. of <br /> the property located at the above site adm-asa hereby outhorlae dee release of any s:d atL rtwAts, 9aotedartesl data and/or <br /> envirormental/sit+ n2stlmah-t Information to SAM 100n III =WY IN NIC RBALTN S1EMCM MIROlRrMAL DEALT! DIVlSllwl 30 moan a <br /> It Is availabla andjat the sane tin it is pre0de4 to Na or W represenratf.e_ <br /> Fee Aanvsnt i AaxAxt PaidOKe of P�1a)/a�ent PsynAn+t TYPE (�^euipt f T71lalT ! R BY <br /> - � <br /> 2� <br /> � � - "I • � - �"fJ -! 'I 1Ibo <br /> AY Y— A4T ......✓....�� Iw1IT CIL <br /> I P� <br />