Laserfiche WebLink
ti 4& 30-1996 4= 15PM FRCS w P. 3 <br /> ?.vv• 0 2 23 95, <br /> DGRAN FILE New Cl+nage Edit (PRO03) revised S/Z1/93 <br /> -try iD N (� -74 as FACI1. i <br /> iftECORD ID i1! �(��3 rR rOR SuFEPs/coo IF <br /> DAIRY: Brads A Crede 8 �^ Milk Diapenaer Nurber of Containers in Matti-Need Unit _ <br /> FOOD: Restaurant Market commissary T Noblia rood Produce stand fee Plant <br />' Seating Capacity Sq Ft - -- 14nrket w/rood Prep. Y / N <br /> Temporary Food rseillty Speclat food event Vendinv Machines Number of Vending Units <br /> Foal Vehicle Make Licen-re M -..._•.,._ ..._ Rtslistratrori M Color <br /> HAZARDOUS WASTE: - Tons Generated/Yr TIERED PE0111 racltlty : CA CE P13R <br /> HOUSING: Hotel/Motel No. of Wl to Jalt/Exempt 11"Mution Housing Abatement <br /> Enptoyee Housing No. of Emptoyeex Ar+prox antes of Occupancy 1 /_ to <br /> LI WED WASTEt Ptw"r Vthlcte .. Pumper Yard T rhemisat Collets No. package Tx Plant <br /> iEDICAL WASTE: Primary Care Acute Care Skilled Nursing _,_ Lo Generator - Sm Generator <br /> Storage (2-10) _ Storage (11-SO) __ Storege C }SO ) Tra>4fer Sto Ltd Neuter Vet Ctinie <br /> RECREATIONAL HEALTH: Pool/spa NufiFr of runt* —_ _ Out of Service Pool Haturot Bathing Place <br /> _ <br /> SITE MITIGATION: Environ AE*ets USr/CAP Loc Naz pa!ite Hai Hat PPL <br /> Other Lead Agency Site Agency: RWOCR DISC NPL Site Re/HZO a — Other <br /> • �_ SOLID WASTE: Landfill Transfer Sta `.._ pecycli»q ram Waste Storage Fac AS wnate/Exrempt Slte <br /> SW Vehicle No, Dix"tlr No. � Stationary Compactor Site <br /> VECTOR COiiTROLt Poultry Farm Max Ntmber of Bfrdm _ T Kerx+el <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NiGHT <br /> CONTACt 1't Gail Pa_tt.Op t 209) 479 5660 t 209) 599, - 6048, <br /> CONTACT z : ( 2 n A) <br /> 0010HATtO EMPLOYEE R l�� PROTgtAH ELEMENT N �R�3 tJ1RRENT STATUS <br /> t OF UMTS I _ EPA 10 ff; -._ INSPECTION COOS 306 <br /> btLLINO and COMPLtAHCE ACUNOWLEDOEMENT: 1, the tr,dersigned owner, operator or agent of same, aekrwultdge that stl site and/or <br /> project apaaifle PHS/ENO hourly charges associated with this facility or activity Witt be bitted 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 wilt be done <br /> In accordance With alt applicable SAN JOAOUIN COUNTY Or•dinanee Codes end/ur Standards and State aril/or Federal laws. <br /> APPLICANT'S SiONATURE : Q EpaVrr ----•- <br /> 4/. V• Ioe Page 1011 <br /> Title: er' / r• G <br /> AUTHORIZATION TO RELEASE 1 ORMATiON: In addtti to the above, When applf able, 1, the ojner, operator or agent of same, of <br /> the preperty't.oeated at the above site address hereby authorize the retease of any and atl results, geotechnieal data andlor <br /> envirerntrental/site assestmtnt information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon a!R <br /> it IS sysllsbte and at the same time it is provided to me or my representative. <br /> Fee Amount Amount Paid bate of Payment Payment Type Receipt 0 Check M Necvd By <br /> 3�v — <br /> IA3 <br /> V 3qo 1I I a-��l(o ✓ 1q, 7D D <br />