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4 ` c 4ERAL PROGRJW FILE s New Ch"e Edit (PRMS) revised SnIM <br /> New <br /> FACILITY 10 0 ✓/ 2 Cj FACILITY NATE <br /> RECORD to 0 (�OD �QS PRiOR SNEEPS/MW 0 <br /> HAIRY: Grade A _ Grede B Milk Dispeiwer Ntstber of Contshm in Multi-Read Unit <br /> FfCOs Restaurant - Market Coamissary Moblte Food_ Product Stand let Plant <br /> Setting Capacity SQ Pt Markot w/Moor4 Preps Y / M <br /> Tenporary Food Facility $peeiat Food Event Vending Machines Nu dw of Voiding Units <br /> Food Vehicle Make License / Registration 0 Color <br /> HAZARDOUS WASTE: Torr Genersted/Yr TIERED PERMIT Facitity : CA CE PBR <br /> HOUSING: Notal/Motal Mo. of Units isit/Exampt Institution Nouaing Abataaerst <br /> ^� Employee Housing No. of Eaptoyees Approx Oates Of OedupandY ,,.J_ f to _1.._m/ <br /> LIQUID WASTE: Pusper Vehidte, Pumper Yard Chaaicat Toitats No. Package Tit Plant <br /> _ DiCAL WASTE: Primary Care Acute Cue Skilled Nursing Lg Generator_,,,,,,• !b Generator <br /> Storage (2-10) St"e, (11-50) Storege ( >'SO ) Trader Sts _ Ltd Hauler_ V!t Ctinto <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of S*rviee Pool Naturat Bathing Ptsce <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Naz Vast* Naz Mat PPL <br /> Other Lead Agency sitz Agency: RWCCB OTSC NPL Sit! ?A/M20 g Other <br /> SOLIO WASTE: Landfitt Trustor Sts Recycling Foe Vast* Storage Fae_„_,r,. All Vaste UMPt Sit! <br /> IRAs V h1sle, Nes Dtwnter No. ��,�, Statienmuy CaapesW Site <br /> VECTOR CONTROL: Poultry Fant Max axber of Birds <br /> EMERGENCY NOTIFiemom for this FACILITY and/or PROGRAM OAT NIGHT <br /> CONTACT 1 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE 0 PROGRAM now ! 2 uRRE1IT STXTU! <br /> S OF UNITS : EPA IO 0: INSPE(?IA CODE s <br /> BILLING and CtalIIM.IANCE A00104t.MXM : I, the undersigned a*er, operator or agent of sews, ackrwAedge that att site and/or <br /> project specifie MAW hourly charges associated with this facility or activity trill be bitted to dw pa ty tdentiffed as the <br /> BILLING PARTY on this foes. I stso certify that t ad this apptieatide and that the worst to be perforwed wilt be dame <br /> in accordance vith alt app dsbte 1OAQUtN COt Ordt Codes and/or Standards and State and/or Federal laws. <br /> APPL " SIGNATURE <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to this above, when appLiabtt, t, tint a*er, operator ar agent of save, of <br /> tine ted at the above site address hereby authorize this release of trop and stt malts, "otedhnieat dsts mndlor <br /> emir tat/sit uses-wane infomtfar to SAN JOAOUiN OCtXTY PURLtC NEALTN SERVICES ENVIR0 MITAL NEALTN DIVISION se soot as <br /> it is avaitsble at the siawa tin it is provided to me or may represenative. <br /> Aaax:ftt Awcunt Paid Data of Payment Pay"t Type Receipt 0' Chwic 0 Roam By <br /> -ILIL4 C <br /> ACCT " UNIT <br />