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FED 06 195 11:33AM 06DEN PROJECTS EJYIRON9ENTFL DFT P.2%2 <br /> GENERAL PROPFAM FILE tlew Change Ed1t (PROW) revised 5121/93 <br /> FACILITY ID S FACILITY NATE L <br /> -.-RECORD ID AM PRIOR SNEEPB/COHP <br /> _ DAIRY: Crede A Grade H _ Milk wisp mer Number of Cantainere in Multi-Read Unit <br /> _ <br /> FOM- Restaurant , Market _ C"issary_ Mobile Food_ Produce Stand— Ice Plant <br /> Seating capacity Sq Ft Market WFood Prep: Y / H <br /> Terporary Food Fooi lity_ Spacial Food Event _ va'dirm machines — Number of Vending Units <br /> Food Vehfole Make Lice ft A' Registration 9 Color <br /> HAZARDOUS HASTE: Tans Generatedfir TIERED PERMIT Facility : CA _ CE _ PDR <br /> HOUSING: Hotal/Motel No. of units JOIL/Exaapt Institution Housing Abatement _ <br /> T+ Employee Nelaing _ No. of Eapleyees � Apprmm Dates of LOOUPIrcy to ---- - <br /> LIaUID HASTE-T PTapar Vehicle,--__ypumper-Yard , Chemical Toilets _ No. Package Ts Jilar&i—:' <br /> MEDICAL WASTE: Primary Care _ Acute Care, Skilled Nursing_ L9 &*nemtor ^- 9n Generator <br /> Storage (2-to) _ starege (11-50) _ Starege ( >50 ) _ Transfer Ste_ Ltd Hauler _ Yet Clinic <br /> CREATIONAL HEALTH-. Pootl$a Rueben of Pools Out of Service Pool _ Natural Bathing Place <br /> Y517E <br /> MITIGATION: Environ Ass i; , UST/CAP ��/Loc Hax Waste ^ Hax Mat PPL <br /> Other Lead Agency site�✓ Agency= RWQCR / stSC T_ NPL Site RH/H2D N _ Other — <br /> SOLID WASTE: Landfill , Transfer STs _ Recycling Fac_ Waste Staraga Fac Y_ Ag Weste/Exempt Site <br /> SW Vehicle_ No. Dumpater _ No. Stationary Cwpactor Site <br /> VECTOR CONTROL: Poultry Fane _ Max Number of Birds Kennel <br /> EMERGENCY NorifICATIOH for this FACILITY and/or PROGRAM DAY RIGHT <br /> cONTACT 1 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE 6 PROMAN ELEMENT # 2 �p CUBRENT STATUS <br /> Y DF UNITS EPA ID t!: INSPECTION CODE - <br /> ,. BILLING ad COMPLIANCE ACKNOWLEDGEMENT: 1, the Ind ' <br /> � ersigrred owner, operator or agent of aa, acknowledge that <br /> all site and/or <br /> project Specific PHS/END hourly chargee associated with This facility or activity will be bi Lied to the party identified as the <br /> BILLING PARTY on this form- I also certify that I have prepared this application and That the work to be performed will be dare <br /> I" accordance with all applicable SAM <br /> S�A,M dOA`WIN ClNTY O/Orrddinance Codes and/or Shat girds and state and/or Federal Lara. <br /> APPLICANT'S SIGNATIRE <br /> Title: C 1.71/0 x Mme. Y �"s'7� Data! ?y <br /> e- <br /> AUTMR17ATECK TD RELEASE INFORMATION: In addition to the ebave, when applicable, If the owner, Operator or agent of Sema, of <br /> the property located at the above site address hereby authorite the release of any and all results, gotechnicat data and/or <br /> amiroansntallBite assessment fnfermatim to SAN JOAoulk CMKIT PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my represairetnve- <br /> Fee AmenT Amount Paid Date of Parent Pryarnt Type Receipt it Check A Recvd By <br /> RENS <br />