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GL*ERAl PROGRAM FILE New Change Edit (PROG3) revised 5/21/03 . " <br /> FACILITY;tp I FACILITY NAME <br /> RECORD ID >X ' PRIOR SVEEPS/COMP <br /> DAA1RYt Grade A Grade'll Mitk Dispenser Number of Containers In Multi-Head Unit ` <br /> FOOD: Restaurant Market Comaissery " Mobile Food Produee Stand ice Plant <br /> Seating Capacity Sq Ft ` Market w/Food Prep: Y / N <br /> Temporary Food Facitity SpecIA Food Event Vending Machines "Number of Vending Units <br /> Food Yetniele Make Lleense iy Regtatreti«i N Color " <br /> iIAZARDOUS WASTE: Tons Generated/Yr. TIERED,PERHIT Faculty : .CA CE PBR <br /> tIOUSINGs Hotel/Matti ` <br /> Me. of <br /> Units" Jail/Exert Institution Nousing Abatement <br /> Eaployee Housing No, of Emptayees Approx Dates of Occupancy <br /> " LIQUID WASTEIM1 Pumper Vehtele PuR,er"Yard Chemical Tollets No. Package Tx Plant <br /> MEDICAL WASTES Primary Care Acute Care Skilled Nursing Lg Generator " Sm Generator. <br /> Storage (2.10) w Storage,(11-50) Storage i .>50 } Transfer Ste Ltd Hauler :.Yet Clinic <br /> RECREATIONAL HEALTH: Pool/spa Humber of Poals out of Service Pooly Natural Bathing Place <br /> SITE MITIGATION <br /> Environ Assess UST/CAP Lac Hex Waste Hat Mat "PPL <br /> T— tie" A : RWOCR DISC NPL Site RB/1120 0 Other <br /> other-Lead Agency S y <br /> SOLID NASTE:y,LandflltJ' Transfer Ste Recycting Fac Haste Storage Fac Ag Neste/Exempt Site A <br /> SW Vehlele No. Durpeter No. stationary Coapaetor Site <br /> VECTOR CONTROLS Poultry FerroMax Number of Birds Kenna ` <br /> EMERGENCY NOTIFICATION for this FACi.[TV "/or PROGRAM _ %DAY" NIGHT <br /> coxTACT 1': Rab Wooton Stockton Savings Bank (209 ) 0 - 6870 <br /> ' ACT 2 ; Mike Holbrook-Clayton."Environmental t510 ) 426 426 - 0106 t ) <br /> DESIGNATED EMPLOYEE 'PROGRAM ELEMENT ! of l S = CURRENT STATUS <br /> r ' <br /> / of UNITS i EPA ID *: -� T INSPECTto" CODE " <br /> BILLING and COMPLIANCE ACICNO4ILEDDEMENT: T, the undersigned owner, operator or agent of"same, acknowtedge that atl site and/oar. <br /> ' project specific PHS/EHD hourly charges associated with this facility or'activity will be bitted to the party tdentlfted as ttW <br /> BILLING PARTY on this form. [ also If y that 1 "have prepared this appticstiom► and that th• work to be performed wilt be done <br /> in accordance with all a cable SAN J QUI "TY nance Codes and/ar Standards and State and/or Federat laws. <br /> APPEICANTmS SIGNATURE Rob Wooton <br /> Page 1013 <br /> Title: Vice President - Stockton Savin s Bank Date: Dec•. 23► 1993 <br /> AUTHORIZATION To RELEASE INFORMATION: ;n addition to the"above,'when applicable, l,. the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> �envirormental/she assessment Information to <br /> SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time It is provided to me or my representative. <br />- t Amaurt Pa td U bate of Payment Payment Type Receipt 0 Check 9 Recvd By <br /> aSHS /t_____f SUPV _/ / ACCs /44 <br /> / UNIT CLK / / <br />