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Y <br /> a ' <br /> C111RAL PROV M FILE Nets ---tame Edit (PRWI revised 5/21/93 <br /> FACILITY tO it (]b FACILITY NAME <br /> a olm lD # Jr 3� PRIOR WEEPS/Cow 0 <br /> �. OAIRY: Grade A Grade a Milk dispenser NuWm of ContalewS in "tt•Nead unit <br /> A: aestaLxant Aarkat Cam wmrY Nobi le Food Produce Stand Id Plant <br /> Seating Ciantity Sp Ft Market Wood Prom Y / N <br /> TEepCrary FOWIfaeitity S>;miat Food Event Vending Mad4inaa Number of Ventlirg Units <br /> Food Vehicle _ � Mak! Licanso d Regiatratlon • Color <br /> 4A2AR"JS PASTS: Tons Ganerated/Ye TIERED PERMIT Faeiltty CA' cE PRR <br /> �[1l1sING: Not*1/Motel Nn. of Units tail/sleep! lnetirutian Heuaine Aho rSON- <br /> of Ecplayees Ap:r" Dote! of OCCLpmey / 1 to <br /> LIQUID LASTt: Pyr Vehicle Pvmor Yard ZeSieal Toitota NO. Package TX Plant <br /> SEDICAL WASTE: Prfawry Care ACUte Care Skilled Nursing Lg Ginrator Sm Generator <br /> :to4-e*4 (2.10) — ttorese (11-sa) _ Sterave ( ?50 y � Tronafte Ct0 ___ Ltd Nauk. vot Clinio <br /> tECREATrONAL HEALTH: Pool/3pr Htxbor of Pools Out of 'lrvipe Peal Natural 04WAS Ptece <br /> -:ITL: MITIGATICtti _srriran Aaawn UST/CAP Lu; Mini waste flit lilt ML <br /> Other Lead Agency Site �� Agncy: ay= vr/ c)rsc NPL Site Rt/HTO 0 Other <br /> SOLID WASTE: Landfilt Transfer Sts Recycling Fac Lust! Stae'apa Fac AD waeta/EX=0C Site <br /> Sal YM1cte NO. F]L>Il>datar Ro. Stationery comamor Sita <br /> '•ECr0R CONTROL: Poultry Farts !4x71 MU=r of airs Kennet <br /> _'ER6E1tCY N(STIFiCATtONI for this FACILITY and/or PROGRAM DAY NIGHT <br /> =(TACT 1 <br /> =TA:T 2 <br /> tISIGMATtO VVLOM R I PROGRAM ELE?4ENT 0 i �9�3 � CLtRMlff STAT7A 7/ <br /> t OF UNITS : EPA ID S: D D WSPECTIOII CCD! <br /> 3iLL:NG ar+d COMaLIANCL ACrJ10YL®GLM[NT: ], fisc wiersigned St t O t no1rit".Re,W&& fait the lT'lFra or101bl�y <br /> project *pacific PRS/EMD houcharges associated charassociated with this facility or activity Vitt be billed to the epparty identified as the <br /> SILL:XG PARTT on this ,foes. I also certify that 1 have 0coated this appli tion"3nd at the wank to be psrfonlied wit be done <br /> fn accordance with alli appLicable S=TY a Codes and/ St to ane/or Federal !alts. <br /> A;PL:CANT1S SIGNATUR11 q <br /> -+,l; State Court Anpoi,ted _ eceiver gate: '- <br /> A.UTHORIiATIOR TO RELEASE INFORKATION: In addition to the Bowe, whom eC94icobte, :, the e .akW,�ReCeiver <br /> :re property locateC art the above site address hereoy tuthorize the retease of any and all results <br /> geoeaehnfeal data s+ne/or <br /> a viroi.m.taL/site ass+essm- information to SAN 40AGUIN C=Y PUBLIC HEALIN SERVICES EMYIROIMNTAi HEALTH DIVISION as soon as <br /> is available and at the same time it is provided to me or my representative. <br /> lee M1oiLnt Qt�Paid �ate of Pay:aent Payment Type Receipt 9 Check it I Recva gy <br /> V <br /> ACCT � 1 ` t87It CLK _/�� <br />