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GENERAL PROGRAM FELE New Charge -R Edtt , (PROG3) rawised 5/21/93 S <br /> FACILITY ID QQ �� FACILITY NATE j �.7 7 �� ►'� ._h �: <br /> �i. { <br /> RECORD IDG PRIOR.StiEF�S/CCl1P / . <br /> DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Nu[ti stead Unet `� <br /> FOOD..' Restaurant Narlcat Commissary <br /> .irobite Food Prodtce Stand r Ica Pant s <br /> Seats i Sq Ft Naritat w/Food Prep: Y <br /> n9 Capao ty <br /> Temporary Food Facility' Special food Event V'"t d Machines s Nu�er of Verding Omits <br /> Food Vehicle Naive Lt0"e G Regia tim Color <br /> tea G <br /> HAZARDOUS WASTE '.Tone Genersted/Tr TIERS PERMIT Facility PSR " 1 <br /> Haut Abetammt <br /> HOUSING Hotet/Notel ~' „'.No. of Units 3at[lExempt Inacitucian t+g <br /> Employee-Housing NO.'of EMLOVees Dates at Orz�perry f ../ to <br /> " TX P ant <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Cheaieat Toilets No. adage <br /> MEDICAL WASTE Primary Care Acute Care SICiI[ed ),ursinq Lg Generator Sia Generator <br /> Storage C2-lO} _-Storage (11 SO) Storage C >SO } Transfer Sta Ltd Hauler Yet Clinic <br /> RECREATIONAL,HEALTH. Pool/Spa <br /> Number of Pools ��, Out of Service POOL Natural Bathing Place <br /> SITE MITIGATION Env!ran Assess UST/CAP too Hae haste =. Naz Nat PPL O <br /> Other Lead Agency 5ito Agony: <br /> RfiCCB DTSC IIPt Si Le RB/HZO 0 4tlw:r <br /> SOLID WASTE Landfill Transfer Stat lRecycling Fac Waste Storage Fac Ag vaste/E�cempc 5tte <br /> Sit Yehicl• No. ,pcaQstar" No StatiansrY CoapsCtor Site <br /> 1Csrr�el <br /> VECTOR CONTROL Pout Fane Wax Ntaobar of Birds ' <br /> e4ERGENCT NOTIFICATION far this FACILITY ad-War PROGRAM DAY NICHT <br /> CONTACT 1 <br /> l /v tf� §- o ST73-r►1 Pr �! is ) 'f Z° ) <br /> C_ <br /> OESFGNATEQ EMPLOYEE <br /> atp PROGRAM ELOW G;` 4 QfRR£NT"S7A7US': � <br /> G <br /> EPA ID G: C o o.d = 0 Z ;� l `V [NS7EciioN`«Y3E <br /> G Of UNITS M <br /> - I <br /> BILLING and.CGMPLIANCE ALIDGENFMTs,..I, the undersigned mner,xoperstor r agent of same,sci�iowladge that al[ site and/or <br /> project specific PHS/MW hourly dm-gm s associated with this'faeitity o< activity wiiE be biLlad to the party idents#ied';aa Lha <br /> .._ <br /> 8[LLING PARTY m this foe+s.. L'alsn`cartify that I haus prepared this-appliwtiorr and that the.work.ca be pertarated wtitl !x done <br /> in accordance with at L.applicabte.SAN JmmtN COIAm Ordinance Codes ardor Standards and Stats mWx Federal aws .' <br /> ../�.-. <br /> .'- APPLICANT'S 51GN12 <br /> ATtlRE ' <br /> rol- <br /> f e <br /> T.tle. .- <br /> AUTHORIZATION TO RELEASE [NFORf:ATION_ In addition to the above, what am i e, r, the aaur,.operacor or a4ent . of ' <br /> the property Located at the`above_sito address hereby authorize the release 6#."any and all rewtts.'.9eacadusieal data and/or <br /> mwirormentaL/site assessment infarmation.to SAN J=tX CMWTY PUBLIC HEALTH SERVICES ENYiR0101ENTAL HEALTH D[VISIDI as sow as <br /> it is available and at the same time it is provided to me or my representsti.w. w <br /> Fee Amoun[. et Date of Payment Payment Tyjm Rempt G -Check # Recvd X81/ <br /> -310 <br /> :10/7 <br /> 17, <br /> I uNi7 <br /> e <br /> REHS �� SIRY ��^ l ACCT L T� CIX <br />