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02-14-1994 02:16PM FROM <br /> TO 17144768211 P.03 <br /> GENERAL PROGRAM FILE New'�d��,,,,, Edit Nftwi- <br /> CPR=) revised 521M <br /> FACILITY IO 0 � FACILITY XW <br /> The 'Rridaes <br /> RECORD 10 d PRIOR SNEEPE/C7" 0 <br /> DAIRY: trsda A Crede 8 MI Lk 0fspenser gL r of Containers in Autti-Mead Wit <br /> FOOD: Restaurant Market COMisssrY_ Stabile Food Ptodut:e Btand as. Ptant <br /> Seating Capacity $q Ft Market w/Food Prep: T / N <br /> Temporary Food Facility, Special Food Event - Yandtng Machines NURbep of Ver4frq units <br /> Food Vehicle Make License N R"Istration d Color <br /> MAWDOUS 'WASTE: Two Generstwr TIERED PERMIT Faitity C CA CE P>IR <br /> BWSINC: Motel/Motet _ No. of Units 44it/Exe pt institution _ Rousing Abetment <br /> Elvloyee Mousing No. of Eployeea A}lprcx Data of oecgancy � � to r. ,,,,� <br /> LIGutb '.IASTI! Pumper Vehicle Pumper Yard Chemieat Toitsts No. <br /> ►aeicage Tx Bene <br /> MEDICAL Wkllf: Primary Care Aeute Care Skilled Nursing L9 Generstor Sad Generator <br /> Storage (2.10) Storage (11.50) Storage C 40 3 _ Transfer Sta — Ltd Nauler _ Vet Ctinio <br /> RECREATIORAL HEALTH: Pont/Spa Number of Poets Out of Service Pact Natural cathing Place <br /> V'SITE M1TICATIGN: Environ Ades UST/CAP Loa Hag Vesta Nei Mat PPL <br /> Other Lead Agency Stta y AggMy: RWOM ✓ bTCC MPS, Bite R!/Waft Q _ Other <br /> SUL10 WASIt., Ianatttl Transfer eta Recycling Fac Waste .S=araW fee . As Wste/Qxeapt Sit* <br /> SW Vehicle Me. cumstar No. R Statianry OoeepaCtor $its <br /> VECTOR CONTROL: Poultry Faro Max NLW*r of ilircis <br /> 0GAGENCT NOWICATICM for this FACILITY and/or PROLRA1l DAY NiCKT ^— <br /> CONTACT t : 21)awna StPDbPnsnn c_202) 474,•1911 (209 ) 9,957 -5279 <br /> CONTACT 2 : Tgevor Santochi, (_Zjl ) 770�0 ( 7Zlj) 729 4887 <br /> DESt=TED EJNPuma daL/�� PROii�AN ELEMENT R ?C4 �jQ CAARAM STA71AI <br /> - mm <br /> li OF UNITS VA tD d: INSI¢ECTiC7N CODE <br /> BILLING and COMPLIANCE ACKNOWUMG XT: I, the undersigned owner, operator er stint of Sara, ackn wiedge that all site and/or <br /> prejaet sp..fifle M/M hourty charges associated with this facility or ativity wilt be bitted to the party Identified as the <br /> SILLING PARTY on this form. I at= certify that I have Prepared this application and that the work Co be performed will be done <br /> fn aeeordanee, with alt amlirable SAN JQAou1N CMKT7 Ordinance Codes and/or Standards and State and/or Federal laws. <br /> ApPLIClaT14 41GIUnUs9Ld-tT4 c4ciA <br /> AUTHORIZATION fO RELEASE 1N ORINT10Ns fre a'diti to the above, when uppiicabte, 1, the owner, operator or agent of sant, of <br /> the Property toasted aQ the aboyq site -` authorise the retease a# ftw ani all rmwtts, gaetachniest data wWor <br /> 4mirw=nt4t/x1te ats"comt information to SAN 40+1i0UIN C(1UM PUBLIC MEALTM SERVICES exVIRCNDIMAL NMTN DIVISION as soM as <br /> It is ovaiteb(e and at tM aaua time it is provided to M or ay rpreaanterive. <br /> Pea Meant Amount Paid Data of Payment Payment Type Receipt 0 Sauk 0 Rem.,q gy <br /> 4Ll <br /> �1 <br /> :E:1ss _J_.J err ..�.J_J AUT �_._! UNIT CU J_..1_.... <br />