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11-02-1994 09:28AM FRIM • TO • 17147790068 P.04 <br /> GENERAL PROGRAM FILE NOW Cnenge Edit (PROD) revised e/26193 <br /> FACILITY Io N - FACILITY MAZE Nestle Facility, 4343 FremontEStockt]o , CA <br /> RECORD 10 C PRIOR SWEEPS/CO"Is s <br /> DAIRY': Grade A ,�_ Grade E Milk Dispenser _ Number of Containers in Multf•Head Chit <br /> _ FOOO: 'Restaurant _ Market _ Caimissery _ Mobile Rood— Produce stand._ Ice Plant <br /> Sooting Capacity SQ Ft Market WFOOd Prep: T / r <br /> Tv,". rYry Food Facility Special Food Event Verdins Machines . Number of Verdins Units <br /> Food vehicle _ Maks License a Registrations Color <br /> _-__,'NA2AROWS WASTE: 'Tons GeneratedlYr TIERED PERMIT Facility CA _ CE _ PER <br /> _ HOUSING; -Hotel/Motel No. of Units._ Joll/EAtrpt Institution Housing Abatement _ <br /> Enrtoyee Housing:_ No. of-Eaployses Approx Oates of OCCW&-cy _J_/_ to <br /> LIOU10 WASTE: Pumper Vehicle Pumper Tard Chenloal Tollets ^ No. Package Tx Plant <br /> MLWICAL WASTEI Priowry Cars Acute Care Skilled Nwraine to Generator_ 94 Omherator is <br /> Storage (2-10) store" (11-00) — Storage i >go ) _ Trwaf/P Its _, Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spo — Number Of Pools out of service Pool — Nstural Bathing Place <br /> K SITE MITICATIOMi Emeviron Assess % UST/CAP Loc Hez Waste _ Rat Mat PPL _ <br /> 'Other Lead Agalty Site _,,,.„ Agency: RW410 DISC i NPL Site — RB/1120 0 _ Other <br /> SOLID WASTE: Landfill transfer Sea _ Recycling fee _ Waste Storage Fee _ Ag Waste/Exempt Site <br /> SW Vehiol'e _ No. Dempster No- Stationary Contester Site <br /> VECroa COYYROL! Poultry Party Ws Mukwe of Rl. k Knvaal �- <br /> EMERGENCY NOTIFICATIONfor this FACILITY ardor PROGRAM DAT NIDNT <br /> COVIACT i , Greg ory K. Mitchell (714) 779- 0052 t_) <br /> CONTACT 2 : Michael. Palmer (213 1 717. (�...) <br /> DESIr11ATE0 EMPLOYEE P PROGRAM ELENEMT 2 NENT 3TATUS <br /> N Or UHTT3.m EPA ID N: o' / INSFitTItNI t�E <br /> BILLING and Cd1PLLANCE AC'KNOULEOGEIIFMT! 1, the mrder4lgned over, operator or agent of Sam, acknowtodte that all site and/or <br /> project specific PNS/ENO hourly charges associated with this facility or activity will be billed to time party Identified as the <br /> MILLING PARTY on.this.form- I also certify that I have prepared this application and that tlta work to be perfonsed will be done <br /> in accordance with all applfcab a SAN JQAOUIN COUNTY Ordinance Cedes ed/or Standards and State mWor Federal tm. <br /> APPLICANTIS SIGRATME <br /> Gror itc ell <br /> Tltla;' Branch Manager Deco: November 2, 1994 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, stemma' Or spent of seal, of <br /> thr pryperty locatad�st the.abava site address hereby ewthafize the release 04 any and all reawlts, saateehndoal data rd/or <br /> emmironseintal/site assessment information to SAN JWWWTN =MY P1XIC HEALTH SERVICES ENVIRONMENTAL HFALTH DIVISION as mean as <br /> It 9a available and at the tsme time it is provided to r.ar ear rspeeentsttw- <br /> Fee Affownt Ancunt Paid Date of Payment Payeont Type Race(Pt / Check iN Remi By <br /> MEns �./J....✓�,.� UNIT at. <br /> R-95/ • 0 i1-02-94 08: 22AM P004 #42 <br />