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Tj--22-199? 10:520[1 FROM <br /> TO 17077613614 F'.02dENER:4. PROGRAM FILE New V Change Edit <br /> (PR0C3) revised S/21M <br /> FACILITY 10 # 7,S FACILITY NAME <br /> RECORD 10 # PRIOR SmPS/COMP k <br /> _, DAIRY: Grade A Grade B _ Milk Dispenser Number of Containers in Nultf-Head Unit <br /> — FOOD. Restaurant _ Market Cammisaary_ Mobl to Food _ Pradice Stand Ica plant <br /> Seating Capacity Sq Ft Market v/Food Prep: Y / N <br /> Temporary Food facility — Special food Event _ Vending <br /> Food Vehicle _ Make License k Machines — Nud:er Of Vending units <br /> Registration # Color <br /> — HAZARDOUS WASTE: Toru Generated/Yr TIERED PERMIT favi Iity : CA — CE PBR �- <br /> HWSING: Note(/Motel _ No. of (hits �_ Jail/Exempt Institution Abatement <br /> Employee Housing __ No. of EMptoYeas ApprOx oat" Of Occtpency __j <br /> /— to <br /> UQUIO WASTE: ?impar Vehicle — Puhner Yard __ Chemical Toilets No. p <br /> aokm9a Tx plane _ <br /> MEDICAL WASTE: PriserY Care Actme Care _ Skilled Nursing — LS Gowator Sa Generator <br /> Storage (2-10) _ Storage (11-50) Storage ( >50 ) Transfer Ste <br /> —. ltd Hauler — Yat Clinic _ <br /> /RECREATIONAL HEALTH: POO(/Spa _ Nudber of POots Out of Service Pool _ Natural Bathing Place <br /> V SITE MITIGATION: Environ Assess C/UST/CAP LOC Hai Waste _ Naz Not PPL `..� <br /> Other Lead Agency Site _ Agency: ZU20 — OTSC ,T NPL Site — 99/H20 0 _ other <br /> SOLID WASTE: lardfitt Transfer Ste _ Recycling Fat _ Waste <br /> SW Vehicle _ No. Storage Fac AS Waste/Exempt Site <br /> Ottapiter _ No. Stationary Coo;:actor Site <br /> — VECTOR CCNTROL: Poultry Fera^_ Max Nubber of Birds KerYhGl —` <br /> EXERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY -- <br /> /l NIGHT <br /> CONTACT 1 ` C�-{��Yii-12 '�eNr ,L� C -�0� -769 <br /> - <br /> CONTACT 2 ( ry`)-1JlGJ_ a 50 (��) <br /> DESIGNATED EMPLOYEE # �� PROGRA11 ELOW k CURRENT STATLtS <br /> # Of UNITS : EPA 10 N. G <br /> INSPECTION CODE : <br /> BILLING and CCHPLIANCE AO NCWLEDGEM )rT: I, the undersigned a~, e <br /> Operator or agent Of semi, ed to ledge that all site and/or <br /> proiact specific PNS/FIND notchy charges associated vitt, this facility or activity will be bitted to the perry Identified as the <br /> RILLING PARTY on this fora. I at" eartify that I have prepared this application and that the work to be patty <br /> Per- Iden,ormod will be done <br /> in accordance with ail applicable SAN JOAQUIN COUNTY Ordfnarca Codas and/or Standards and State ard/Or Federat Laws. <br /> APPLICANT'S SIGNATURE Cacti /�0 rp <br /> TitterIZTON TO REEI/e I mGc oat*:—. J���3 <br /> AUTHORIZATION TO RELEASE tNfORMA ON; t—'xddn itim to the above, when applicable, I, the Oscar <br /> the property located at the above site address her r oparetor or agent of sons, of <br /> awirormentat/site assessment informtion to SAN JOAOU M �,Ty the rel ane of arty and all results, Baotachnfcal data and/or <br /> it is avaflab(e and at the same time it to Provided to ar or PUBLIC HEALTH SERVICES UylROMWAL HEALTH DIVISION as Sean as <br /> my epresmtattve. <br /> Fee Amount Aman Paid Date Of Payment A <br /> ayaent type Receipt k Quik # Rwvd By <br /> ACOT <br /> —77 <br />