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07—6-1'D93 04: 13FP1 FROI'l TO 4621381 F.0 <br /> G�NEHAL P1R19RAM FILE New _ +'p+'f�e tali trctwo, ravisra ]/l�/Y] <br /> FACILITY 10'0 FACILITY NAME J <br /> RECORD ID 1 �( PRIOR SWEEPS/COMP it <br /> DAIRY: Grade A Grade S Milk Dispenser _ Number of Containers in Mutti-Mead Unit <br /> _ F000: Restaurant Market Commissary Mobito Food Produao Stand Ice Plant <br /> Food vehicle — Make License 0 Registration 0 Color <br /> Seating Capacity Sq Ft Markat w/food Prept Y / N E of Verdtng Machines <br /> HoU51NG: Notet/Motel No. of Units - _ Jail ,,,,,,,,,, Employee ACU6114 No. of <br /> LICUID WASTE. Pumper Vehicle Pumper Yard Chemical Toilets No, i_ JPa Package Tx Plan <br /> 1993 <br /> RECREATIONAL HEALTH: Pootlisps Nvrber of Pools Out of Service Pool _ Natural Bathing Plage <br /> ENVIRONMENTAL HEALTH <br /> -2SITE MITIGATION: Environ Assess UST/CAP Loc Hat Waste .._.__. Naz Mat PPL, PERMIT/SERVICES <br /> Other Lead Agency Site Agency. RWGCB OTSC NPL Site RB/HZG 0 Other <br /> SOLiO '.TASTE: landfill _ Transfer Sta Recycling Fac Waste Storage Pao _ Ag Waste/Exemt Site <br /> SW Vehicle No. Ounpster No. Stationary Compactor Site <br /> VECTOR CONTRCL: Poultry Farm r, Max Humber of Birds Kenuiel <br /> for this WILITY and/�911 DAY <br /> CONI CY NQTIFiCATI � C`y <br /> a o ) <br /> CONTACT z <br /> DESIGNATED EMPLOYEE )tcap <br /> PROGRAM ELEMENT 0 9 / CURRENT STATUS V•'j"�� <br /> EPA i0 �. r9 Approx Oecupai Dates rte/ to 1 ,/ <br /> N Acq Of UM, r INSPECTION CODE <br /> BILLING ACKNOWLEDGEMENT: i, tho undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHO hourly charges associated with this facility ar setivity wilt be billed to the party identified as the BILLING PARTY on <br /> this form. <br /> I also certify that I have prepared this aKptiestion and that the work to be performed will be dans In accordance with alt SAN <br /> 40AGUIN COUNTY Ordin d Standards, State and Federal laws. <br /> APPLICANT'S S NATURE <br /> Title: Date: © �� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnicat data and/or <br /> envirorm+ental/site assessment information to SAN JOACUIN cOUNYY PUStIC HEALTH !MRVICES ENVtAONMEN'tAL HF-ALTX DIVISION as soon as <br /> it is available arxi at the some time it is provided to me or cry representative. <br /> Flmu <br /> Fee Amount Ant Paid Date of Payment Payment Type Receipt 4 Check 9 Recvd By <br /> l <br /> SUP v /. . /. .. .._ ACCT /_.____. / � UNIT CLIC <br />