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M14eRAL pROGRM'FILE t New Change Edit � 4rena3l revised 5/Zl/93 <br /> FACILITY 10 # FACILITY NAW <br /> RECORD 10 A PRIOR &MEDS/COHP M <br /> DAIRY: Grade A Crede a HIM Dlape a*r — 106*1 of Containers In Nultl=Ned Unit <br /> FOOOt Restaurant Market co missary Mobile Food Prod=* Stand Ice Plant <br /> ing Capacity "+Q Ft Market w/Foal Preps T / a <br /> T oS*Seot <br /> at Food Facility Special Food Event Venlino Machines Nucber of vending Units <br /> Food Vehicte Make License h _ Registration If Color <br /> m <br /> HAZAROCUS uASK: Tons Genersted/Yr .......�.—. TIERED PERMIT Facility t CA CE POR <br /> NaUSING: Notet/Motai No. of Units 1. jsIlAxempt Institution Nousing Abatement <br /> Emrptoyee Housing No. of Eaptoyees ,,,, Approx Dates Of O=t4mncy to -----,/-----/ <br /> LIQUID HASTE: Pumper Vehicl* Pumper Yard Chemical Toilets No. Pecks" Tat plant <br /> MEDICAL UPS IE: Primary Care Acute Care Sklttad Nursing Lo Conerstor Sam Generator <br /> Storage (2-10) Storage I11-5OI Storage t >5O ) _ Transfer Sts _„•_„ Ltd neuter „_ Yet CLinle <br /> RECREATIONAL NEALTHt Pool/Spa Number of Poot! _, Out of Service Poot Natural Bathing Place <br /> SITE HITIGAttONs Environ Assess USt/CAP Loc Nat Nast* max Mat PPL <br /> other Lead Agency Site Agency! RVOCA DISC NPL SiteAB/H2O 0 Other <br /> SOLID wret LandfItt transfer Ste Reeyctin0 Fac Masts Storspte Fse Ad Naste/Exampt Site <br /> kle— <br /> SSU vehicle No. ...._.._..._._-- Dunpet*r No. Stationery compector Site <br /> vECiOR CONTROL: Pouttry Far* Max Number of alyds Ken"at <br /> EMERGENCY NOttfICAfIOM for this FACILITY and/or PROGRAM DAY NIGHT <br /> ? 111 t <br /> ) . <br /> CONTACT 1 e ""•"" ~ <br /> COHTACt 2 ! 15, <br /> DESIGNATED EMPLOYEE <br /> PR EIEMENt;D414161at StAtt1S <br /> ! of UNITS t EPA 10 N! INSPELtioll CGDE s <br /> BILLING and ccWt-DANCE ACJ=KEDCENENt! 1, the ond*rslowd owner, operator or agent of wase, acbxart*dge that sit sit* andlor <br /> project spackle PNS/EIsD hourly dwrg*s associated with this fscitlty or activity Vitt be bitld to the P*rty Idsntifid ae the <br /> SILLINB PARtY on this force. l Otto eartify that t have pr*w*d this apptication and that the work to be performed wilt be dons <br /> In accordance with att applicable SAN JOAQUIN COIAITY OrdirsarmA Cadet arrdlor Stax!*r•de and State and/or Federal tows. <br /> APPLICANTS SIGNATURE <br /> TItte: bate! <br /> AtJtItORIZATtON TO RELEASE INFONNAtION: In addition to the above, mhot spptleebte, t+ the arewsr, Operator or agent of $on*. of <br /> the property toested at the above site address hereby authorin the raisese of any end Ott res+ulta g*ot*chnicat data and/or <br /> envirotmentat/site assessmmt Information to SAN<RAMA CaNtY MALIC'NOW SWtCE! NVIRONMEXTAL NU►Ltil 0#Vlslail as soon ae <br /> It is`mwatlabta and at the saws time It to provided to are or my representative. <br /> Foot Anoint Anoint Paid Date of Propent Payment type Rec*Ipt 0. Check ! R*cvd SY <br /> ACCT <br />