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a <br /> �c!SER►L PROGAAIS %!UE New change "edit (PR+DG3) revfitd 5/21/43 <br /> FACILITY 10 S FACILITY NAIL <br /> RECORD 10 a PRICR SLIEEPS/C w a <br /> DAIRY: Grade A ode 8 Milk Dispenser Nutter of Containers in Multt-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile food Produce Staid Ice Plant <br /> Seating Capacity S4 Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Machines gtpber of Vending Units <br /> Food Vehicle Make License 8 Registration R Color <br /> HAZARDOUS WASTE• Tons GeneretsdtYr TIERED PERMIT Facility : CA CE PBR <br /> HO(1SING: Hotel/Motel No. of Units jail/Exeapt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Oates of Occtperxy _fes to <br /> LIQUID WASTE: pj*er Vehicle Ptnper Yard Chemical Toilets No. Peckage Tx Plant <br /> _ <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing lg Gawetor 9a Generator <br /> Storage (2.10) _ Storage (11-50) Storage C >50 ) _ Transfer Ste Ltd Hauler Vet Clinic <br /> RECR£ATiCHAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Hai Waste H82 Mat PPL <br /> Other Lead Agency Site Agency: 2=2 ✓ OTSC NPL Site R8/H20 0 Other <br /> iSOLID WASTE: Landfill Transfer Ste ••..^ Recycling Fac Waste Storage Fee Ag Waste/Exempt Site <br /> Stationery Come tor Site <br /> SW Vehicle No. Ouapeter No. <br /> VECTCR CONTROL: Poultry Fara Max Number of Sirds 1Cen et <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PRCZM OAT NIGHT <br /> CCNTACT 1 ; George Forsythe (209 )275 - 4968 (209 ) 485-5833 <br /> CONTACT 2 : ^CLP\/P CTra i t ( 209)275 . 4968 (209 ) 438 •8611 <br /> PRN)GRAII ELEHEWT 41 llei �' C3=XT STATUS <br /> OESIGNATED EMPLOYEE 4 7— c <br /> INSPECTION C <br /> ;t OF UNITS <br /> S <br /> EPA 10 3; E <br /> 31ULING and aCNPLIANCS ACXNOWLEDGEMtxT: 1, the undersigned o+.ner, operator or agent of same, ackwwledge that all site and/Or <br /> project specific DHS/END hourly charges ass4Ciated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on rhis form. I also certify that I have prepared :his application &rid that the work to be performed will be dory <br /> in accordance with aft applicable SAIL 4CAOUIN C:OURITY Ordinances Ccdes and/or Standards and State and/or federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> Geologi st Date: 8/29/95 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the Drier, operator or agent of same, of <br /> the properry located at the above site address herevy authorize the release of any and all results, geotechnical data and/or <br /> environnentallsite assessment information to SAN :OALTUIN CCLINTT PUBLIC HEALTH SERVICES -:XVIRCHKE)1TAL HEALTH DIVISION as soon aro <br /> it is available and at the same time it is provided to me or my rpr <br /> eesentative. <br /> Fee Amount I Amount Paid Date of Payment Payment Type I Receipt 0 Check R ` Recvd gY <br /> RENS I 1_/�/ ACCT �� I V I UKIT CLX <br />