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a3-30-1996 12:09PM FROM <br /> • P. ,d <br /> • Pw K <br /> MGRAM FILE t Mev CDMge Edlt (PROC3) revised 5/21/93 <br /> try 10 _.5 7� 3 L-� —. —.. FACILITY NAIL <br /> RECORD 10 -_�Q 9 30 PRIOR SUF.EPS/COMP f <br /> DA1RYt CFO& A _ Grade B Milk Dispenser , Nurber of Centolnera in Multl•Haed Rnit <br /> FOCOi Restaurant Market Cemmisser'y —_ MObI(e Food Produce Stand Ice Plant <br /> Sewing Capacity SQ Ft Market w/rood rrrpe Y / N <br /> Temporary Food Facility _ Special Food Evane Vendlna MPchlnea Ninber of vend Inv U17 to <br /> Food Vehicle __ Make Llcenme M Realstratlmi of Color <br /> HAZARDOUS WASTE[ Tons Genersted/Yr _ TIERED PF•RMIT Fsclllty : CA CE PBR <br /> — HOUSING: Hotel/Motel _ No. of Units J411/Exeept institution Housing Abotetrnt _ <br /> Employee Housing T No, of Eap(oyeem Arsov Dates of Occupancy / to <br /> `_ LIOUID WASTE Pt/rpar Vehicle _ Puvnr Yard C.I, ,Teal Tolleta No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care _ Acute Cnre —__ Skilled Nursing �. La Generator _ Stn Generator _ <br /> Storage (2.10) _ Storage (11.50) _ Storaoe ( e50 ) _ Transfer Ste _ Ltd Hauler Yet Clinic <br /> _RECREATIONAL HEALTH: Pool/Spa _ Hu brr of Pools __ Out of Service Pool — Natural Bethlng Place _ <br /> ;_ SITE MITIGATION: Emlren Assess Iz UST/CAP Loc Ilaz Unite Hat Mat PPL !_ <br /> Other Lead Agency $Its Agency; RLOCR W DISC NPL Site RB/H20 0 Other <br /> — SOLID WASTE[ Landfill Transfer Sts _ Recycl lag me Waste Storage Fac _ Ag Waate/Exempt Site <br /> SW Veh itis No. OnntAte, —. Na. Stationary Compactor Site <br /> VECTOR CONTROLS Poultry Farm . MAX Nnmtrr of Blyds Kennel <br /> EMERGENCY NOTIFICATION/for this FACILITY and/or PROGRAM DAY NIGHT , <br /> CONTACT I /Iz3 <br /> CONTACT 2 <br /> MIGRATED OPLOYEE I PROrAAM ELEMENT I , .�L"� , <br /> �� f� CURRENT STATUS <br /> 0 OF UNITS i EPA 10 9: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned amer, operator or agent of seas, aekro (edge that all site and/or <br /> protect slueeif fe PHS/END hourly charges associated with this facility or activity will be billed to the party Identified as the <br /> BILLING PARTY on this Ions. I @too certify that I hove prepared this application and that the work to be performed will be done <br /> In accordance with all appllcsble SAN JCA0UIW COUNTY Ordinance Codes ord/or Stadards and SCatebYid/IM'fe�'�7ateT`leNb: <br /> APPLICANT'S SinGNATUIE : //✓f r,� <br /> TI it*.- S,, ,,j Date! / �c7—��/`6 1'age 1011 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when sfpl[cable, 1, the owner, operator or agent of sant, of <br /> the prtperty located at the above site address hereby authorize the release of any and all results, geotechnfcal data and/or <br /> envlrcrrx:ntat/sfta assessment Info~jon to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a soon as <br /> it Is available and at the seer time It Is provided to me or my representative. <br /> FesAmoLot Anotatt Paid Date of��77Payment Payment Type Receipt 0 Check 0 Reevd By <br />