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. e <br /> . GZME?AL PROGRA?I FILE New _ "hange Edit CP200) revised 3/26193 <br /> FACILITY ED 9 1 / 7 7 p FACILITY M"e <br /> ;ECCRO ID * I :5-0,5 4,c <br /> PRIOR SWEEPS/C7v 2 <br /> DAIRY: Grade A Grade 3 Milk Dispenser Ntaber of Containers in Multi-4ead Unit <br /> FOCO: Restaurant Market Ccmaissary Mobile Food Produce Stand Ice Piant <br /> Seating Capacity So Ft Market w/Foad Prep: T / N - <br /> Twrvorary Food Faeitirt Special Food Event Vending Machines Nuiaber of Verrdine units <br /> Food vericte Mance License t Registration I Color <br /> AAZARDaJS WASTE: Tons Generated/Yr TIERED P£RMIT Facility : CA CS PSR <br /> _ HCtISIHG: Hacel/Mocel Ho. of Units Jail/Ezespt Institution Hoeaing Abstemenc <br /> Etroloyee 4ousing No. of Esplayees Approx Dates of Occt.pw=y _f_J to <br /> LICUID WASTE: Pumper Vehicle Punier Tard Chesical Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing La Gnerator SIB Generator <br /> Storage (2-10) storage (11-10) storage ( 3.10 ) Transfer its _ Ltd Hauler _ Vet Clinic <br /> RECREATIONAL <br /> HEALTH—Pact/Spa Number of Pools Out of Service Pool Natural 3athing Place <br /> v SITE MITIGATION: Envirtn Assess UST/CAP Loc Rat Waste y Max Mat PPL <br /> Other Lead Agency Site Agency: ZWC3 OTSC NPL Site RE/H2O Q Other <br /> _ SOLID 'TASTE: Landfill Transfer Sta Recycling Fee Waste Storage Fac Ag Waste/EXempt Site <br /> 7d vehicle No. ot=ster No. Stationery Czaipector Site <br /> VE='OR CCHTRCL: Pouttrf Fara Max 4ti ber of airds carrot <br /> er= <br /> :2+cPrc tC. 40TIFiC.lTION for his FACILITT and/or PROGRAM DAT MIGHT <br /> Cl,"ITAC' I C ) ( ) <br /> CCNTAC' 2 ( ) ( ) <br /> DESIGNATED e(PLOYE: f I 06 g)'/ I PR=Ax ELE31T ! I Z9- 53 aJR2M STATUS <br /> 3 OF UNITS EPA ID t: II IItS?ECTIQI CmE S� <br /> I 3ILLING and =MPLIANCE ACXXCWLcMGM0XT: I, the undersigned arrlsr, operator or agent of sae, acknowledge that sit sit! and/or <br /> .• proj specific PHS/-HD hourty char7r3 associated with this facility or activity will be Silted to the party Identified as the <br /> a 3ILLING PARTY on this ,'ora. I also certify that I �have prepared this efplication end that the work to be performed rill be done <br /> in actzrdancer with all applicable JOALiJi Ordirance Codes ardor Standards and Ststa and/or Federal law:_ <br /> APPLIrixT'S SIGHATLMS : /�/ l J �U/1 <br /> P (U ?--� "I <br /> j <br /> T i tte: ✓ ftDatta <br /> AUT;CRIZATICNi TO RELEASE !MFORMATION: In addition to the above, when applicable, I, the mint, operator agent of seise, of <br /> the located at the above site address hereby ardforiie the release of arry and all results, geacvchnical data rsi/or <br /> envir-vrencai/site assessment information to SNI JOACUIII CUKTT PMIC REALTR SEMCES 3-MMllENTAL KMTH HVISIM as soon as <br /> it is available and at the same time it` is provided to me or ay rep ego- ztivle. <br /> Fee Arrrornt I Amoint Paid I Date of Psysaxrt Payment Type I Receipt t 1 neck t I Rttyd 3y <br /> moo:= ► I ' ' I <br /> 2E45f UNIT =X <br /> a tt A <br />