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GENERAL PROGRAM FILE New Claoge Edit (PROG3) revised 5121/43 <br /> FACILITY 1D M / 1C < FACILITY NAME �� -7O <br /> ! -} (F 1 � GLt f lF7l.,I <br /> RECORD ID N J^ 1 PRIOR SVFEPS/COMP N <br /> DAiRY: A ( Grade a Milk Dispenser Number of Cmtainers in Mutti-Heed Unit <br /> FOOD: Restaurant Market CoRmiasnry Mobile ro-ci rrrA-)Lpee Stand Ice Plant <br /> Seating Capacity Sq Ft _ _-_ Nnrket u/ro'xi rr.p: Y / N <br /> Temporary Food Facility Special Food E-.4nr — Verriing Mnchlnes Number of Vending Units <br /> Food Vehicle Make _ LIcrncr d - _ Registratic+ri 0 Color <br /> HAZARDOUS WASTE: - Tons Generated/Tr __ TIERED PERMIT Facility CA CE reR <br /> HOUSING: Hotel/Hotel No. of lhiits Jnil/Exempt institution Housing Abatement <br /> Employee Housing No, of Employees _-_ _ Approx Dates of Occupancy _/ / to <br /> 110U1D WASTE: Pumper Vehicle Pcrrper Yard -_ _ Chrmicnl Tolletn No. Package Tx Plant <br /> MEDICAL HASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) Storage t X50 ) Trrntsfer Stn _ _ Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Poot/Spa Nunhrr of Pnnls _ Out of Service Pool Natural Bathing Place <br /> XTE MITIGATION: Environ Assess V111" UST/CAr __ Loc liez Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWOCR _^ DiSC NPL Site RB/1420 0 Other <br /> _ SOLID WASTE: Landfill Transfer Stn Rrcyclinq me Haste Storage Fac Ag Wa4te/Exempt Site <br /> SL Vehicle No. Dkxnp<ter _— No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birdv Kernel <br /> EMERGENCY NOTIFICATION for t�hhis FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 s '54ev-& (2a1 ) q&-g - Zrtso ( ) <br /> CONTACT 2 �1Vk► �t..)�n <br /> DESIGNATED EMPLOYEE 0 O it PROGRAM ELFMENT N _Q JCURRENT STATUS <br /> N OF UNiTS EPA ID 9: f INSPECTION CODE <br /> BILLiNG and COMPLIA14CE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ail site and/or <br /> project specific PY.S/EHD 'hourly charges associated with this facility or activity will be billed 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 done <br /> In accordance with all applicab! JOAO N COUNTY Ordinance Codes and/or Standards and State and/or Federal taws. <br /> APPLICANT'S SIGHATLiRE <br /> f <br /> Title: ' ? ?Jpw Date! P(rge 1011 <br /> /� / �V�—G 14� — r <br /> AUTHOR17ATICR 0 RELEASE TNfCR--`---MATIO0 in aikiticn to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the rrccerty loci- d --t .__. e s?tr hem authcrixe the reteas± 14 my and all results, geotechnical data end/or <br /> enviror.nent.31/1i: S.�h lmi -CU)m ?UGLIC HEALT=I SZRvtCE5 ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the same time It is provided to rex or my representative. <br /> Fee AiZt Amcwt Paid Date of Pay-vat .Payment Iypz *:•aipt z Check N Recvd By <br /> i E <br /> ACCT ( lC _ -^ UNIT CLK _I / <br />