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r d-23-1997 2:d3PM FROM P. d <br /> jRpGR/Y1 FILE : New Chm►,ge Edit (pROG3) reviseed 5/21/73 <br /> by t0 0 FACILITY NAME <br /> i Coto to a Palo" swops/CORP a <br /> DAIRY: Grads A Grade 0 Milk Dlnpenser weber of Cantatnero in Multi-Need Unit <br /> FOOD: Restaurant Market Comais,ann•y Mobtle rood Pros*sce Stand lee plant <br /> Seating Capacity Sq ft Market w/rood vrrp: T / N <br /> Teeporery Food Facility Special food Event Vendtrg ""chines Nusber of vending Units <br /> Food Vehicle make Licen4e N _ Regietretiai O Color <br /> HAZARDOUS WASTE: Tons Genereted/Yr TiERED PERMIT rocI lfty . CA CE PSR <br /> HOUSING: Notal/Motel No. of th,ita Jett/Exeeept Institution Rousing Abatement <br /> Employee Housing Ito. of Ersployees Atvwox Dates of Occupancy / / to <br /> LIQUID WASTES Pusepor Vehicle Purrer Yard Chemical Tottets No. Paekege Tx Plant <br /> MVICAL WASTE: Priwary Care Acute Care _ Skilled Nursing Lg Generator Stn Generator <br /> S.torego (2-10) Storego (11-SO) — Storage, t >50 ) _ Tron+fer $to Ltd Neuter ,rte Vet Ctinte r„ <br /> RECREATIONAL HEALTH: Pool/Spo Nu*er of Pools _ Out of Service Pool Hnturet Bethitro Place <br /> " SITE MITIGATION: Environ Aseera --�Z UST/CAP Lac Ilei Waste Nat Het PPL <br /> other Lead Agency Site Agency: RUOCA �— DiSC "Pt Site R9/820 O Other <br /> SOLID WASTES Landfilt Tranefer Ste Recycling me Waste Storoge Fee All ueate/Exeapt Site <br /> ...- SV Vehleto No. DIS Ater No. Stationary Conpector Site <br /> VECTOR CONTROL: Poultry Form Mere Umber of airdq � Kennet <br /> EMERGENCY NOTIFiCATION for thin FACILITY and/or PROGRAM DAT NiGNT <br /> CONTACT 1'f Oweln k, <br /> CONTACT 2 < ) <br /> MIGRATED EDWW if !/ PROGRAM ELEMENT it CURRENT STATUS <br /> 0 Of UNITS I EPA iD 0, INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT! It the undersigned owner, operator or agent of oamm, acknowledge that all site end/or <br /> project apacffic PNS/EFW hourly charges associated with this facility or activity will be bitted to the party identified as the <br /> VILLING PARTY an thin form. I also certify that I hove prepared this application and that tho work to be perfonaed will be done <br /> in accordance With all oWliccable SAN JOAQUIN COUNTY Ordinance Codes and/or St"ards and State and/or fedarol taws. <br /> APPLICANT'S SSGNATURE 1 <br /> Page 1 of; <br /> Title: � ��- tss.1 Date: �' <br /> AUTHORIZATION TO RELEASE INFORMATi : In addition to the above, when applicable, 1, the 4mr, "rotor or @.Sent of saw, of <br /> the preperty`l.ncated at the above site address hereby authorize the release of any and all resutta, geotechnical dato and/or <br /> envirormzntal/alto onsessmrnt inforasstion to SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OIViSICa as Soon ae <br /> it is available and at the somas tuna it is provided to me or my representative. <br /> Fee Amota/t Ammot Paid Date of Payment permit Typo Receipt 0 Check 0 Recvd gy <br />