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7-17-1997 1 :33PM FROM P. 3 <br /> RAN FILE : New Change Edit (PRO03) revised 5/21/93 <br />;;: D) <br /> 1fY Io Y FnclllTr Hhwo iD r PRiOR S%JF.ErS/CCHP NRTt Grad* A Grade a Milk DlRpe+,ser Nrrrber of Containers In Multi-Head Unit <br /> row: Restaurant Market Commissnry - -T Moblir ro-d Produce Stand Icr rlant <br /> Seating Capoclty SrT Ft ��- ---_- Mnrket w/rood rr.r: Y / N <br /> terrTmrary Food Facility SpeclAl Frod Fvr-nt -_ Verdlno Mnchinea NLx0>&r of Verding Units <br /> Food Vehicle Make LlrrnRr N - RegtRtratio6 N Color <br /> -_ HAZARDCUS WASTE: Tons Generated/Yr _- TiERED PETZHI1 Facility : CA CE rBR <br /> HOtU__SiNG: Notel/Motel No. of th+its Jail/Exevrnt 1114titution Housing Abatement <br /> Eeployee Housing No, of Errptoyeei -- �- At%prnx Ont" of Occurnncy �J / to <br /> LIQUID WASTEt Purrper Vehicle Pinar Yard --- rh, IrAl 10110tR No. Package Tx Ptm,t <br /> MEDICAL WASTE: Primary Care Acute Cnre - SY-Illed Nursing -�- Lu Generator Sm Generator <br /> Storage (2-10) Storage (11-SO) `�- ctoroq& ( >50 ) Tronafer Stn Ltd Hauler T Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Nu*hrr of rool-t -- Out of Service Pool Naturist Bathing Place <br /> St TE MITIGATION: Environ Aikens !/ UST/CAr _ Lac ilat Unite HaL Hat PPL <br /> Other Lead Agency Site Agency: Ruaca -- DiSC - NPL Site R0/H20 0 Other <br /> SOLID uASTEt Landfill Tren•fer S1A Rrrycll ,q me vaate Storage rac Ag urate/Exeopt Site <br /> Su vehicle No, Dirrfat�r _^ 40, Stetlonary Com3metor Site u <br /> VECTOR CONTROL: Poultry Form Mnx )4rrrMr of Blyd-t Xerv,wl <br /> EMERGENCY NOTIFICATION for this FACILITY sod/or PROGRAM DAY NiGHT <br /> CONTACT 1 '1 /kS. _f c�'a An-e— 90 ) y 87 v 3C; z- <br /> CONTACT 2 ( ) ( ) <br /> —� E i <br /> W IGNATED EMPLOYEE Iir 1±1 PROr.RAM FLEMENT / �//� CURRENT STATUS <br /> Y OF UMTS EPA iO 0: ( INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the ur,dtrslgned owner, operAtor or agent of saner, acknowtedge that all site end/or <br /> project specific PHS/EHD hourly chargee assocleted with this facility or nctivity will be billed to the party identified as the <br /> BILLING PARTY on this form. i alrao certify at i hnve prepared this Application anis that the work to be performed wilt be dons <br /> In accordance with all applicable SAH J H COUNTY Ordlmmnce Codes and/or Standards srd State and/or Federal taws. <br /> APPLICANTrS SIGNATURE /-Z� r75. <br /> /• I '' y� 1'frl;r 1011 <br /> i <br /> Titlat-_—Z� e' C�-c` c-Sf�"� Date: 7 L <br /> AUTHORIZATION 70 RELEASE INFORMATI� addition to the above, when applicable, i, the owner, operator or agent of seine, of <br /> the prcperiy located at the above site nddresi heretry authorize the release of any and all results, geotechnical data end/or <br /> envircrrnental/alta eaaestrrnent inforaution to SAN JOAOUiN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIC" •>: soar an <br /> it Is avaitable and at the same time It is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Paym.nt Pnymcut Type Receipt N Check 0 Recvd By <br />