Laserfiche WebLink
1 1-07-1 996 2:d9PP f FROM P. 3 <br /> �ey <br /> Aim;i M Fite : New Change Edit (P"r,11) revisrd 5/21/03 <br /> )f�Ty in IF FACILITY NAME <br /> 11tCOAD los T- <br /> (A0* PRIOR SWF,EPS/camp 0 <br /> DAIRY: Crede A Crede a Milk Dixpencer Ntmber of enntalners in Multi-Head Unit <br /> FOOD: Restaurant Market ronmlasaory —_ mpbllr rxl Prexluce Stand fen plwnt —_ <br /> Seating Capacity Sq Ft Mnrket u/rood rr.p: T / N <br /> Teeporary Food Facility Speclnl rood Event Vendlnv Mnchlttes Nurber of Vending Unita <br /> Food Vehicle Make Llcense N Reolstratlai 0 Color <br /> HAZARDOUS WASTE: Tons Generated/Yr —_ TIERED PF,RMIT facility : CA CE POR <br /> NOUSINC: Hotel/Motel No. of thtita Jnil/Exempt Institution Rousing Abatement <br /> Employee "easing No. of E:rployees —_ Arprox Dates of Occupancy to --J--/ <br /> LIDUID WASTET Pumper Vehicle Pt-mer Tarr! __ f'l+rm{cnl toilets No. Package Tx Plant <br /> MEDICAL UW E: Primary Core Acute Cnre Skilled HtrsIng _W_ l0 Generator Sm Generator <br /> Storage 12-10) Storage (11-SO) Stornoe t >SO ) Transfer Stn Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Poot/Spa "urbor of Pf!ols ,- Out of Service Pool Notvral Bathing Place <br /> V--,-SITE <br /> /SITE MITIGATION: Environ Assess USr/CAr Loc flat Wnate list Met PPL <br /> Other Lead Agency Site Agency, RWOCR Disc NPL Site Re/1420 0 Other <br /> SOLID WASTEI landfill _ Trans(er Sl* Recyclli+o me lunate Storage rac Ag Waite/ExeMpt Slit <br /> SM Vehicle No. Onmt+Qtir Ne. stationery Compactor Site <br /> VECTOR CONTROL: Poultry Farts Max NtnMr or Birdq Kerrvrl <br /> EMERGENCY NOTIFICATION forthis '�FACILITY or, //or IrROGR T �^ DAY NICHT <br /> CONTACT t rNC�4R,. �.ctr�l �• cStD )94� �3 y ESto y d 3'� - <br /> CONTACT 2 <br /> DE3ICHATED EMPLOYEE ! PROGRAM ELEMENY 0 CURRENi STATUS r <br /> 0 OF UMTS 2 EPA ID !: INSPECTION CODE <br /> BILLING std COMPLIANCE ACKNOVLEOGEMENT. 1, the undersigned owner, operator or agent of two, acknowledge that all site end/or <br /> project specific PNS/EHD hourly charges associated with this facility or ectivlty witl be bitted to the party idefW/ taRtfi e <br /> BILLING PARTY on this eons. i also certify that f hnve prepared this application and that the work to be perfo�4wEA`� <br /> In accordance with sit app le S N J UIN COUNTY Ordinnnee Codes and/or standards and State end/or Federal 1840. <br /> MAY w 9.1997 <br /> APPLICANT' SIGNATURE : <br /> JC1Ni-,j-'og rOi Off <br /> C <br /> Title • HEA- <br /> Date, \� .,� BLIC t'�Cr�,.'. , SERVICES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, a owner, epere dA{o?C)1t94M_W. 0 ,ls' I°N DIVISION <br /> the property'(ocated at the above site address hereby authorize the release of any and all results, geotechnical date and/or <br /> envfrormentol/site assessment Information to SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as <br /> It is available end at the same time it Is provided to me or my representative. <br /> fee Amount Amount Psld Date of Payment Payment Type Receipt N Cheek IF Recvd By <br /> 1 <br />