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JAN- 7-99 FRI 12:46 FM P 5 <br />OF <br />IfimmLe : Rev thange Edit (Pt%3) revived 3/21/03 <br />A41 <br />2fD/O( 0 (/NAM <br />coso Io r Dv8 3� 3 PRIOR awf.ErS/Cato # <br />OAIRyi tirade A Oreda : Milk Oispert.er Nrsrber of Crvrtolners In Multi -Road larTT <br />10M.- Restaurant Market t:arrtelitenry MobTle re7tl Frfxkce Stand fcr, pleat <br />Eestary t:npaelty . Sq Ft k,.rket v/roorl rr.T+r T / M <br />1 -orrery Food facility Speetel rood Ev.,nt �__ Vtrdine MocTrlrref Nurber of V"Iriv th,lt• <br />Fuca vehicle Make L1renge M _ _e Reeistretfai # Color <br />NAIARVWS UASrCr Tons C"retw$/1'r __ <br />IMSTNC: Notal/Motet No, of tRrlts <br />Erro(oyee Rousing No. of FRplayee. <br />TIM0 FR4011 recttfty s CA cE rRR <br />J1911/ENtopt irrittitvtien Mouslrq Abort (Mm.ret <br />Arrrnx DAtes of 0mrinnCY _� / to <br />— tIOU10 UAITET ry . r vihfclt Fr%"" r teat Vhr lrnl TOtlota MO. _ Peekope Tx tont -. <br />REDICA.t Mitt Prlstary core Acute Cere __ Skilled tlurslr+g __ t0 Generator Sm Generator <br />•— Storage (2.10) _ Stars,* (11.50) � Storage t P50 ) _,a Irar.tfer Stn — ltd Navter _ vet Clinic __ <br />REMATiONAL NE41.1113 root/Spa Nurbor et root! Out of Service root Natvral 1401111 Fiace <br />/_ <br />311E MiTiGATiOMt Environ Asseca x U$rjCAr _ toe list unite _— Rat !lett PVL <br />Other teed Agefloy site Agency: RWCR Disc PIK site Rg/NIO o other <br />Soup tmsm terdrttt _ Tr*n#ltr Ste _ Recycllt,o rno _ w•itt Storage Fac All ww4te/Exe"Pt Site <br />sw Vthlcis No. ! , 0urtrater No. 31atlonary Con"etor Site <br />viCTOa CONTROtt poultry Farm Mex kvrf"r of Slyd• Kerry! <br />EMERG(NCT NOTIFICATION for this FACILITT ad(or rROGRAM DAT N14NT <br />CONTACT 2 <br />OttICNATEO EMFLOTEE f 1 1 FROGRAN ELEMENT # 1 ' QXRENF STA" <br /># or URI TS I EPA 10 9: <br />IRsFQCTiOR CCDE : <br />EILITaO aped COMPLIANCE ACXMWLIUCIMENT: 1. the Uldaratgned o4»er, Operator or a9errt of 11saw, seknowiedge tt'st ail site and/or <br />project apscifie FNS/END hovrty chsrgea associated with this facility or oetivity Vitt be billed to the party Identified ss the <br />11ILLi146 FAityr on this tory*. I slso etrtify that I hnvt prepared this appl(catfon and that the work to be par#vr+ned will bo dens <br />in secardanes with ail spoliesbit SAN joapUlli COWTT Ordinance Codes ord/or, Stsfdards srd State srd/or Federal laws. <br />AFFCICATar+9 StG1fATURE `- -'4- <br />��Gt cT 1 "age I fill <br />1 YW-2..y— Ce -4 .r O{CC_- Date: -7 TOl { f <br />AUi1wRItAT,ON TO REJEA39 INFORMATIOw: In addition tote above, when Irolieabte, 1, the owner, operator or alitht of state, of <br />the prorxrtyrlocstsd at the ab ve site address hereby authorlte the riltase of any and alt results, geotechnieel date and/or <br />enytrorraental/stte asstaentnt inforetatlon to SAN JOAOUIa CWNTT ML IC UFAL1N SERVICES ENVINONP ERTAL RE.ALTN DIVISICM ss foo+ as <br />it Is avallabla erd at the same tints It Is provided to " or my reprete+rtative. <br />