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11-07-1996 2:d9Pi i FROM P. 3 <br /> Pr/,immLE : New Chmiae Edit (PROG3) revised 5/21/03 <br /> )(lTT iD 0 ,� �� FACILITY NAME <br /> i�ECORO toll! (������� PRIOR SwFErS/COMP s <br /> DAIRYt Croda A Crede A Milk Diaperaer Number of Containers in Muttl-Read Unit <br /> OL <br /> FCOD: Restaurant Market rom"Isgely -_ Noblle ro,>d Prew*vcr Stand Ice Pl*nt —_ <br /> Seating Capacity Sq Ft Market w/rood rr.r: Y / N <br /> tem )a ary Food Facility Spocinl rood Event Vendino Mnchlvies Ntr+er of Verdlma Units <br /> Food Vehicle Make Liernse N Reglstrmt(omi N Color <br /> HAZARDOUS VASTE! Tons Cenerated/Yr -_ TIERED PERMIT fmoility . CA CE POR <br /> HOUSING. Notal/Motel No_ of Wits Jnil/Exempt institution Nousing Abatement <br /> Employee Housing No. of Employees —_ Approx Dates of Occupnncy / to <br /> tIOUTD VASTEt Pumper Vehicle Ptmx r Yard __ Chemical Tollets No. Package Tx Plant <br /> MEDICAL VASIE! Prlmary Core Acute Cnre Skilled Nursing LO Generator Sm Generator <br /> Storage (2-10) ^ Storage (11-SO) _ Stornar ( >50 ) 1ran4fer Sto __ Ltd Hauler _ Vet Clinic <br /> /RECREATIONAL HEALTH: Pooi/Spa Htpher of roots --___ Out of Service root Neturel Bathing Place <br /> V SITE MITIGATION: Environ Asaecs UST/CAP -_ Loc Hoz Unste list Hat PPL <br /> other Lead Agency Site Agency! RVOCR DiSC NPL Site R8/HZo 0 other <br /> SOLID VASTEt Landfill _ Transfer Stn Recyc(I"o Fnc Vmote St*roge Fee Ag Vette/Exempt Site <br /> W Vehicle No. Durp.ter me. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Fart" Hox wears of girds Kennet <br /> EMERGENCY NOTIFICATtOM for this FACILITY std/or-PROGRAM DAY NICHT <br /> CONTACT 1 'i C�� i-� , -� ��C' ) I� - l��L [�I l) ) I �� •�C 'J <br /> CONTACT Z <br /> DE3IGHATED EHPLOTEE 0 �'(j J/ PROGRAM ELEMENT 0 � CURRENT STATINS <br /> 0 OF UMTS s EPA 10 !: r` INSPECTION CODE 3 � <br /> BILLING and COMPLIANCE ACICHOVLEOCEMENT: 1, the tndersfgned owner, operator or agent of *tyre, acknowledge that oil site end/or <br /> project specific PNS/EHO hevrty charges associated with this facility or mctivlty wilt be bitted to the party Identified es the <br /> BILLING PARTY on this form. i also certify that I hnve prepared this application sed that the work to be performed will be done <br /> In accordance with ell applicable SAN JOROUIN COUNTY Ordinance Codes and/or Stmdmrds and State ad/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> �� / Cj/ 1,41"r 1011 <br /> Title: Date: �1�`1!1�,1- I 7� <br /> AUTHORIZATION TO RELEASE INFORMATION: tn'eddition to the mbove, when applicable, 1, the owner, operator or agent of smme, of <br /> the prope•rty'(ocated at the above site address hereby authorize the release of any ard all results, geotechnical date and/or <br /> environmental/site assessment information to SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a! Soon as <br /> It Is available end of the same time it is provided to me or my representative. <br /> fee Amount Amovtt Paid Omte of rmyment Payment type Receipt M Check 0 Recvd By <br />