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GENERAL PROGRAM / ,FILE sew Change_...._.-.�- Edit _ (PRDG3) revised 5/t8/93 <br /> FACILITY ID d FACILITY RNA Central Cellars <br /> RECORD IDS PRIOR SmPS/CtMP ii <br /> DAIRY: Grade ► Grade s" Mitk Dispenser Yu�ber of Containers In Matti-head Unit <br /> '�'' F1�: Restaurant MarketCasnissarl► Mtbite Fold Pradace Stand ice Plant' <br /> 5es[i:�g Capacity�_ .Ft Market w/Food Prep: Y /' N di <br /> Ruttier of Venng Machirm <br /> feed Yeh{els hake License afi Registration # Coles <br /> Togs CeneratedlYC TIERED PERMIT Facility . CA !>' <br /> "'"' '' ilAZARD[I!S VAST£: ,-•--- <br /> `''"• F�ONSING: Notet/Motat �_ No. of Units: _ doll/Exeopt institution <br /> Nasi Yo, of Enpleryees Apprax Dates of opmoor�cy _J to <br /> IF tayee r �.. <br /> : package Tx plant <br /> LIGUID WASTE:' Kx4mr Vehicte .. Puy w.Yard Chemieat Taitets No- _ <br /> MEDICAL WASTE: PHONY Care <br /> acute Caro�i- skilled Nursing L0 Generator Sm Generator,_ <br /> Storage (2-10) Storage (tt-5Q) storage t >50 ) ._ Transfer Ste Ltd NauLer Yet minic <br /> s? Out'of Service Poel Iiat�rst Sathino Ptau�. <br /> 7RECREATIONAL WE Poot/Spe rm 'iturber of ➢gals "2 met <br /> SITE NITIGATIOH: Enviran Assess UST/CAP Loc Mai Waste un Site <br /> em LR8/N2fl Q Other <br /> other Lead Agency Site Agency: VA= �._ DTSC <br /> sotm WISTE: Laedf�It fPansfBr 5tt _, Ruing Fee Waste, StIlew.'Fec'� AS VMte/EJcaoQt Site <br /> S1i Vehicle NO. �..� <br /> Duapster Nv. : , Concector Site <br /> statior+ery ' <br /> VEcloR CONTRdL: Pwt-try perm Na% Nor of Birds ,,;; :.: XeMel <br /> DAY <br /> apmRGE:= AOTIFICATIOU for this FACILITY ardor PROGilA1I <br /> Y1G8T' <br /> VernonDeWu.l (209 .368 5151 . . _ c209= 9�3135.8.^ <br /> CONTACT 1 <br /> CMACT 2 <br /> CLMU <br /> DESIGM►Td ELEMENT <br /> IOYEEEP,a ' • ATt� <br /> d Of UNITS <br /> EPA ID #-. CACO 401.019 49 .. INSPECTION Carr <br /> that alt site and/or project spacific <br /> BILLt9a ACL7OAMGMMT: I. the u ldersigned owner, operator or ggaest of same, edv+oi+ledne ` <br /> PYS/EmD bourly chargassociated with this jar <br /> es itity or activity gill tier bitlsd to the party identified as the BILLiYG PARTY ar+ <br /> "ih{s form. : <br /> red this iaation and t et the work to be perfortaed mitt be dm In accordance uJth.att SAN. <br /> so cart that I ha" pi red l tales. <br /> "•JOAal11) Cmn TY Drdirtiae+ee and Sts S a and <br /> `APPLICANT'S SItdiATUkE <br /> ;`::iitte:Vice P esidenir ��es C a e • when applieabie, i, the airier; rotor or agent of- 6 18_19911:��, . <br /> same. of <br /> : .ALyT�lbRI7ATIOM TO R£f.EASE INFORMAYICaI: Ir: addition to the above, and ell results, geatechniaal dais and/or <br /> ':. <br /> The property tocoted st the abaft site address hereby suthariie the rebase of arty► <br /> .srivirormantal/site assessment {nfdrratian to SAM .IOAALIIY CD7JNTT PLiBLIC HEALTH SEW <br /> EINIROIQIEKYAi iiEAtYtI DIVI$IG11 es soar+ as y <br /> it is available and at the same time it is provided to me or sy rapreeenta <br /> Fee "cmt Affmxmt Paid Data of Payment Payment Type Receipt # Check d Recvd By <br /> UNIT <br />