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07/01/96 16:33 CITY STKN ACCTG 94683433 N0.449 1?03 <br /> GENERAL PROGRAM FILE New Change LEdit (PR=) revised 5/21/93 <br /> E <br /> ID f a9� fAUCJT7 NA,iEi0 i /D� �OC�� PRIOR SWEEPS/CCW P <br /> DAIRY: Grade A Crede 5 Milk Dispw*er Number of Containers In Multi-Held Unit <br /> FOOD- Restaurant Market Camoisaary Mobile Food Produce Stand lc! Plant <br /> �— Seating Capacity SQ Ft Market w/Food Prep: T / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make license! Registration S Color <br /> NAZARDWS WASTE: Tons Generated/Tr TIERED PERMIT Facility : Ch CE PIR <br /> MOUSING; Notet/Notel No. of Units Jail/Exnpt Institutien Nousing Aboteolent <br /> Employee xaming No. of Eaptof�ees Approx Dates of Occupancy_J�/ to <br /> LIQUID WASTE: Ptapsr Vehicle Pumper Tord Chemical Tollets No. Package Ts Plant <br /> MEDICAL WASTE: Primary Care AWte Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) , Storage (11-50) _ Storage Transfer Sts Ltd Nsuler _ Vet Clinic <br /> _ RECREATIONAL HEALTH: PooilSPs Number of Pools Out of Service Pool Natural Bathing Place <br /> ZSITE MITIGATION: Environ Assess UST/CAP LOC Naz Watts 21(—' Na= Not PPL <br /> Other Lead Agency Site Agency: 'RWOCI DiSC NPL Site Rg/NZO 0 Other <br /> SOLID WASTE: Landfill Transfer Sts Recycling Fac Waste Storage Fac Ag Wasta/Exempt Site <br /> SW Vehicle No_ DuaFster No. Stationary Coap=tor Site <br /> VECTOR CONTROL: Poultry Farm Ms: Wider of girds Kennel <br /> EMERGENCY NOTIFICATIou forr�this FACILITY andlon PROGRAM DAY NIGHT <br /> CONTACT 1 -. �••1 � AA�s� ( fit) 737 . 37-0 ( , <br /> CONTACT 2 <br /> OESJGNATED EMPLOYEE t O tp� PROMM/ELEMEYT N ?.���Zf CfIRRENI STATUS <br /> K Of UNITS EPA ID ig: <br /> IISPECTION CODE <br /> BILLING and CM4pLIANCE ACGOdLEDGEMERT: 1, the undersigned ager, operator or agent Of 61010, acknowledge That all site and/or <br /> project specific MIEND hourty charges associated with this facility or activity will be bitted to the party identified as the <br /> BILLING PARTY on this form. I also certify that I hive prepared this application and that the work to be performed will be dors <br /> in acCordsrceI'G'RitAhTUO1":X" N Ordinance Codec and/or Star+dards and State and/or Federal laws. <br /> APPLICANT'S <br /> 1 <br /> If -711 <br /> Title- Date: <br /> AUTHORIZATION TO RELEASE tN,O Y IW: In add it LO above. when applicable, i, the aver. operator or agent of same. of <br /> the property located at the above efts address hereby alltbarixe the release of any and all results. geotichnicsl data and/or <br /> environmental/site assessment information to SAN J0=1% COUNTY PUBLIC REALTH SERVICES EBVIROMIMAL NMTH DIVISION as 6001 as <br /> it i6 avaitable and at the cam time it is provided to me or my representative. <br /> ca. Am Int Amount Paid Date of Payment Payment Type Receipt >r Check It Recvd By <br /> iii �a 3'f -- �a 3 4— ��a-��?(o ✓ ` `�10�� l,�S <br /> i <br /> RENS _/ � suav A X-/ UNIT CLC <br /> 'z <br />