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RA)1 FILE t Nev rX.I Change Edit (PROG3) revised 5/21/93 <br /> LITY�iD 1 �,.} r�'�e`i_v;.rq?•3;�•°'- F/1C'LITT NAPE <br /> PRIOR SIVE ?S/"i.••.r; 'YRECCRD ID iif .�` ;-•y2'r�'h�,,; ;?w.#•�::::'+1..�. _ ( c <br /> _t THwwVY'.,f,�1rtt•T.. 'kY.w.v. r .,+`-:.;5' ....�.•.�. <br /> r.'.' il�X r-j•i+Ji`1ohY::y�sfr.�.. . :L�, (�.., 4 <br /> ice`'�• . DA1RTt Grade A~" Grade 3 Milk Dispenser Nuroer of Containers in Mutti-Heed unit <br /> 'L,.•'••:1_' fOCAt•Y: Restaurant' `•Market Commissary Mobile Food Prvdese Stand Ten Plant <br /> Seating Capacity Sq Ft Marret w/food rrep: T / H <br /> �.Twsrporary Food FmeILIty Speeiat Food -Event Vendfrq Machines 4urter of vending Units <br /> ' Food Vehicle* Make License X Registration i Color <br /> RAZAROCUS HASTE: Toro Generated/Tr TIERED PS71M1T Facility CA C PSR <br /> HCUSING: HoteliMetal We. of Units :ail/Eserrpt institution Housing abatement <br /> E:rployee Housing No, of Eactoyees Ar-lrox Dates of Occ;.per y _/ / to _J_f <br /> L1CUiD WASTE: Pusper Ventcis Ptsr"r Yard C:+.•-Tical Toilets Ho. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled .4L.-Sing 1p Generator Sm Generator <br /> Storage (2.10) _ Storage (11-:0) Storoge ( >50 ) Tronsfer Stn Ltd 4euler Yet Clinic <br /> REC.%EATiONAL HEALTH: Pcol/Spa Hurcer of roots out of Service Pool Natural 3athing Plan_ <br /> SITE MITIGATION: Environ Assess UST/C.tP lac Haz Wnste Haz Mat PPL <br /> Other Lead Agesr/ Site Agency: RWCC3 Disc NPL Slte RB/H20 7 Other <br /> St:tID WASTE: LardfTll Transfer Sta Recyctirg Fae WASte Stcrage Fac Ag Waste/Exerpt Site <br /> SW Yehleie No. ou:pcter Me. Stationary C--rnpactor Site <br /> VECTOR CCHTROL: Poultry Fern Max Hu,rbor of Birds Kernel <br /> EME,TGEYCT NOTIFICATION for this FACILITY and/or PROGRAM DAT HIGHT <br /> CCITACT 1't <br /> CCNTACT 2 <br /> DE§IGNATED E?iPLOYEEe ! PROGRAM ELEMENT i I aJRREHT STATUS I <br /> 3 OF UNITS EPA ID is INSPECTION CME <br /> BILLING and COMMIANCE AtXACWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> Prefect specific PHS/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 applicable SAN jOACU1N COUNTY Ordinance Cines end/or Standards ars! State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: Page 1011 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the rreoerty•loeated at the above site address hereby authorize the release of any and all results, geotechniesl data end/or <br /> environmental/site assessment inforaation to SAN JOACUIN =UHTT PUBLIC HEALTH SERVICES ENVIROMMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to are or Ary representative. <br /> Fee Aaaxnt Asyut Paid Date of Payment Payment Type Receipt 0 Check ! Recvd By <br /> RENS _/�/ SUPV _/ / ( ACTT _,/ / UNIT CLK _/ / <br />