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•,,[aFTAL VI'VRRAM FILE NOW halt <br /> FAC;tITY 10 a f '— FACILITY NAPE <br /> �� rLRD fD x I i -1'" PRIOR SWEEPS/COMP <br /> OAIRYI ^Grade A Grade B - Milk Dispenser •r.�� Hutber of Containers in Multi-Head Unit <br /> _ F000: Restaurant _ Market Commissary Mobite Food _ Produce Stand Ice Plant <br /> Fob Vohicle Mak" _ W Y Llc mRe d Registration b Color <br /> �Speting Crpaeity Sq Ft Market w/food Prep! <br /> Y / N 11, <br /> of Vending MaChfnwa <br /> HOusiNG: Notel/Notal No. of Units Jail Employee Housing No. of Employees <br /> LICUID uASte- Pumper Vehicle PLrrper TO rd _.__ Chemical Toilets No. Package Tx Plane <br /> RECREATIONAL HEALTH: Pool/9po Nurbosr of Pools out of Service Pool Nsturat Brthin9 Plaee <br /> ZITS NITIG%TIONI Environ AaSees UST/CAP Los Hai Waste — 401 Met PPL <br /> Other Leed Agency Site Agency: RWOC9 __ DTSC NPL Site RB/H$O 0 Other <br /> $CLIO .TASTE: landfill transfer Sta Recycling Fac Waste Storage Fac Aa Waste/Exl!upt Site <br /> SW Vehicle No. Du Aster No. Stationary Compactor Sita <br /> vE^_TOR CONTRCL: Poultry Farm Max Numlx r of Birds Kerv*t <br /> FvEiGENCY NOT[FICAT[ for this FACILITY and/or PR DAT <br /> COPI T. ..,.,. .. <br /> C04"Act z <br /> !tet�• AQ��.,,�,�t,,�.�';"�-/G�i'i� <br /> 'OLFS10ATED "PLOYEE 0 r -2. PROGRAM ELEMENT 2 j D CURRENT STATUS <br /> EPA i0Approx Occupancy Dates / / to �..-..�-/ <br /> )V.'HnER OF LIMITS -u -- p INSPECTICH CODE <br /> attLIN4 ACXNCWLEO4F_NENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/END hourly charges assoeisted with this facility er activity will be billed to the porty identified as the BILLING PARTY on <br /> this form. <br /> I at-to certify that I have prepared this apptitation and that the work to be performed will be done In aecordAnce with alt SAN <br /> 10AcUlN COUNTY Ordin nd Standa"k, State and Federal laws. <br /> APPLICANT'S S ,MATURE <br /> Tltln• --. — <br /> AW RCRIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the pr-perry located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirermnntal/site aesescment information to SAN JOACUIN CWNTY PUBLIC HEALTH SERVICES ENVIRQNMENTAL HEALTR DIVISION as soon As <br /> it is avoltabte and at the same time it is provided to me or my representative. <br /> . Fee Amount Amount PAfd Date of Payment Payment Type Receipt g Check 0 Peevd By <br /> I ys StJPV - � •% / ._ = ACCT �,/ / UNIt CLK /_ f <br /> IF—_ _ "" <br />