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Tuesday October 4, 1994 17:10 -- Page 3 <br /> 10-04-1994 05:04PM FROM ✓ TO 19169208463 P.03 <br /> GENERAL PROGRAM FILE New u►ange Edit �rxt�;,1 rsvlsed 5R1/g3 <br /> FACILITY ' �!3�J FACILITY MALE <br /> RECORD iD ! /.)�'�/�� PRICK 9fix /CCHPP 0 <br /> DAIRY: Grade A Grade t T_ Milk Diaptr,eer Number of Containers In Multi-Neod unit <br /> FOOD: Rsstaur t HarkaC COM13sar•Y Moblto Food Produce• Stand Ice Ptant <br /> ~^ Seating Capacity Sq Ft - gartst w/Food Prep: T / 11 <br /> TeeporarY�Facility Special Food Event Yendlry Machines wxt*r of Yvidirg Units <br /> iovd Vehicle (take License ! RaQistrstian i Color <br /> I ' <br /> NAZARDCM UASTE: `` Tons Genersted/Yc TIERED PtWIT FacititY : CA Ce M <br /> HOUSING: Not lll/Motet No. of Units .tait/Exempt institution Omming About <br /> P-mplayee Rousing 11o. of Employees Approx wea of Occupancy <br /> LICUIO WISTE: Xam <br /> ;w Vehicle Pumper Tud Cbtcal Toitats No. Pockat" Irk Plant <br /> II <br /> NO[CAL WASTC: Prinary Care Aautr Care Skittod lursinp Ld Generator Sae Generator <br /> '^ Storage (2-10) _ Storage (11-50) Storage ( 3,50 ) Trwwfer Sta Ltd hauler Yet Clinic <br /> i <br /> RECREATIONAL WM*H: PootlSCe Humber of Poots out of Service Pool Naturst Bathing Place <br /> I <br /> SITE MLTICAtION: IErwiron Assess V-' UST/CAP ,L� max Wats W Heat PPL <br /> other Lead 1l9ericy Site Ad&,Cyl RUX3 ✓ DTSC NPt Site R$/Q0 4 Other <br /> SOLID UhSTE: LmvfilL Transfer SLe Recycling Fie Unto Storage Fac Ag iih-MrEza.pt Site <br /> stiff V0 icti Na. T� Duppater No. stationary Compactor Site <br /> 3 VECTOR CONTROL: I Poultry Fame Itax Naber of dtrds *'r1el <br /> EMERGENCY NOTIFICATI�q for th#s FACIL[tT and/or PROGRAM DAT NIGHT <br /> CONTACT t <br /> DES[GMATED * Z PROGRAM E[F1R lIi f C31tRE11T STATIiS <br /> 3 OF UNITS : CPA i0 t- I)MML-TION Ccag <br /> BILLING and CWLLANCE ACO A1LEDCBEXT: I, 1110 undatslgned oww, operator or "me of sorer sckrwwtad" that ail Sit* and/or <br /> project specific VVQ hourly dwr9es associated with this facility or ee[ivity mitt be bitted to the party identified as tM <br /> BILLING PARTY on thi (or*. I also certifY tMt I have preparod Chia application and that the wort to be Performed mitt be done <br /> in accordance with qItl aWti so JOAQUIN =XTY 1 and/or Stwxkrds &-d hate and/or Federal taws. <br /> APPLICANT'S SIGH: <br /> Title: s b ��o�«� ����� — cream .QRte: DCr� - - - <br /> XUTNORILtT�MICtASC IN TION: In addition to lbs abavi, ~ applicable, 1, the z;;. operator ar ag+nt of smee, of <br /> due property tacst-q at thwsbare site address bereby MAborit,e the rMleate of amp and At, remits, gptachnical drta and/or <br /> wwironeentst/site 4&-ssrent information to SAM 409W1H CWUfY PUBLIC )IMTiI SEWCES 511HIit01MWffAL WALTM DIVISION all sm as <br /> it is available andjit the easia time It is provided to se or qr reprasantative. <br /> Fee Amount i Amotett Peid Dere of Payment PNyoalt Type Receipt t Cheek 0 R BY <br /> ACE;TUNIT CLX �,...� <br />