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7—'23-1997 3:48PM FROM P. 3 <br /> u/ Edit (PROG3) revised 5/21/03 <br /> AO" FILE s New Chnna- _ _- <br /> tfTY 10 / 71 / -- FACILITY NAPE <br /> >♦ELYJ0.0 10 I PxlJOTS Is —._..._.. PRIOR sur..Ers/CCMP R—__.—.—_ . ._ <br /> DAIRY% Orada A Crede B Milk Dlapenser Nts.bor of Containers In NUlti-Heod Unit <br /> Carniesn: Mobile rax! Produce stand __ Ice Plant <br /> F000: Reatawant Market �Y _.— --- <br /> Seating CnpocitY Sri Ft Mnrket w/root( rr*p: N Y ! <br /> Ta"p°rnrY Fuad faellltY __ special food Evef•t — Vendt+4 MAchine, — MLeber of Vvditg Units <br /> LleMne ! Realatretioi M _ Color <br /> Food Vehicle �_ Make __..J.._ <br /> _ <br /> HAZARDOUS WASTE!-. •- Tons Generated/Yr _ <br /> TIERED PERMIT racllity : CA _ CE <br /> _ HOUSING: <br /> Na. of Uti to Jnil/Except trntltut iat Housing Abatement <br /> Eapioyee Housing !_ No. of Employee+ Ar.rrox Dates of Dceupeney _/_/J to --�� <br /> _ LIWiD UASTEt Ptnpar Vehicle Pug.rr Tnrd _ Cl.Amlcat Toltetn No. Package Tx Plet+t <br /> MEDICAL WASTE: Primary Care !. Acute Care _ Skilled Nursing LZ Oenerstor __ sm Generator <br /> Storage (2-10) _ Storage (11.50) Storape < >50 ) Tratnfer Ste — Ltd Hauler __ Vet clinic <br /> ��RECREATIONAL HEALTH: Poot/Spa _ Nv:her of Pools Out a( Service root _ Natural Bathing Ploce <br /> ✓ SITE MITIGATION: Environ Assess g UST/CAP Lac Net Woate NPL site Het PPL0.glH2O 0 �_ Other <br /> Other Lead Agescy Site __ Agency. RUOCA Disc .� <br /> Trannler StRecYciing roe Waste StaraOe Fac Ag Want*/Exeopt Site <br /> SIR SOLID WASTES Landfill --- -- Statlonary cct:pector site <br /> SW Vehicle No. DnR+ster No. <br /> VECTOR CONTROL: Poultry Farm _ Max Nudr_r of girdKervrl <br /> s --- __ <br /> u— ------•_- DAY NICHT <br /> EMERGENCY NOTiFICATION for this FACILITY and/or PROGRAM <br /> CONTACT 1 1 Gary LaDllz i n <br /> (209 ) 942 - 0417 <�) <br /> CONTACT 2 • Renee van de Griend (510 ) 655 • 7400 t—) <br /> L�l / I: PROGRAM ELEMENT 1 aq`5� L�RRENT STATUS <br /> LOYEE <br /> DEtIGNA1E0 EMPl� `( <br /> I OF UNITS t EPA 10 Nt <br /> INSPECTION CODE �T) rl <br /> r agent of Bess, acknowledge that all alta and/or <br /> BILLING and CONPLIANCE ACKNOWLEDGEMENT: 1, the undersigned Amer, operator o <br /> project specif is PNS/EHD hourly charges associated with this facility or activity will be billed to the pert` crnrdlfied will e"s the <br /> dorm <br /> BILLING PARTY on this (Drat. so also certify that I hove Prepared this application and that the work to be Paf <br /> In accordance with sit, afpticabte SAN JOA COUNTY Ord <br /> inontt Codas "jar Stddnrda and Scots and/or Federal laws. <br /> APPLICANT'S SICNATMIE C Q V QNB <br /> Title. + Octet <br /> I'age 10 <br /> AUTHOR I2ATIpf TO BELE INFORMATION. In addition to the above, when eppileebie, 1, the owner, operator or agent of same, of <br /> the property I Located at the above site address hereby aut"Hze the reteese of any and all result,, geotechnical data and/or <br /> mvirgraw:ntallsita assessmnt Information to SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon 31 <br /> It Is available and at the sacs time It is provld*d to me or my representative. <br /> Fee Aanasnt Aso nt Paid Date of Payment polwent Type Recelpt I check 0 Recvd EY <br />