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FPO 11 05%01/95 14: 57 P . if <br /> i' <br /> ji{OORIIN PILE 1 NewChange Edit (PROOI) rtvl*ed 512I/0I <br /> .% X__ <br /> it.IO g FACILITY NNW <br /> MIT lip IF ~�' PRIOR swEErs/COM N <br /> DAIRY* Orad* A ter, Grade a Milk olatautr ______ Rtnt»r of Containers In Multi Ned Unit <br /> rocs, Restaurant _ Market Ctmmlseary __ Nohi It ro*d _ Proikm:e stand, let Plant _ <br /> WAIng CRpee1tY tit fl _ _ _ Market w/rood Prep! T / N <br /> Ieeporery food I■elllty _,,,,_, speelal rood Event — Verdiry Mochiiee _ N r of Vending Units <br /> Food Vehicle _ Risk* Lieenee N ......... Reglatretlai I Color <br /> KAZANo01Js vilsial tons 9awrsted/Ir _ TIrREo PERMIT raclllty r CI _^ CE _ rell <br /> _ NOUSINOr Neb1/Metel Mo. of Unita _ chit/ENMpt Ilmlltutio, NouHnp AWnment <br /> Soployme Mousing — Ne. of ERployees !� ApproR oaten of oec"mY _/ I_ to <br /> LIQUID IN19191 PuWar Vehicle _ Purger TWO Chemleel Toilet" Me. Package t* Plant <br /> MEDICAL NASTEI ►riesry Can Acute Care skilled Nursing Lp Cenero�or ,_„_ to Conarator <br /> • StorMt it-IO) _ Storage 01•110) — Storope 1 >So ) trmnstar Sto __ ltd Neoler _ Yet Clinic <br /> _ RECREATIONAL NEALSNt Pool/Spe Nu+er of Poole Out of Service Peol NatUtol sathing Place <br /> SITE MI110A/MTNt Emlrm Asaess UST/CAP Loc list UestP — Nat Nat PPL _ ___ <br /> other Led Agency Site — Agency: Rusca Oise _ NrL site S/N20 0 — other <br /> toL10 WABIC, Landflll Trenafer etaRecyelnq roe _ Nast! Storage roe � As Neatt/Extapt site <br /> — W Pehiele No. `_ ovgnllr __ No. 9t■Ilmory Coapeter Si la <br /> _ VECTOR CONTROLt poultry Form _____ Max NurMr of Blydt _ Kerrwit <br /> ENERCENCl, NoTIFICAyION for this FACILITY ad/or PROGRAM DAY u+ Y NIONi <br /> CONTACT 2 L& Dmo <br /> 0911CPATE0 EMPLOYEE • U�`� I PNOP,RAM EIENENI S a G'� CURRENT i1A1Us <br /> OR CODE <br /> S OF Utllls 1 EPA 10 f: IMS C1I <br /> BILLINO and CONNt.IANCE ACKItMEDOEMENit 1, the undersigned owner, "rotor or agent of stems, eknowledgt that alt sit* ad/or <br /> "Itet specific PhWfo hourly charges associated with this facility or activity will be billld to the party Identified as the <br /> SittIMO pARTy on this form, i also certify that 1 how prepared this application end that the work to be performed -111 be done <br /> In accordance with dl/Rr+plkeble SAN JOAWIN COUMir ordirunae Codes ad/or 6tedardt ed Stat11 and/or F*dent laws. <br /> APpIICM111 11 lIATURE I\ Page MHn <br /> AUTNORIZATIOM TO RELEASE INFORMATION, In addition to the above, when spplleable, I, the Owner "rotor or agent of sane, of <br /> the propertyrloeatd at the above site address hereby eutherlze the release of any and all nsnlitts, 9e0technle01 data andlor <br /> enylrYw Mntal/alta OBSISWMMt InfaPstion to SAN JOADUIN COUNTY PUBLIC NEALTN SERVICES EMYIRtENTAL MEALiN DIVISION ae soon ■s <br /> It Is available and at the sane tiffs It Is provided to me or or, representative. <br /> Its Amaalt AR % Psid vote of Portent Peyntetit Type Asetlpt B Check R Recvd By <br /> SUPV _/_..�/�� ACCT <br /> __ v <br />