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GENERAL PROGRAM FILENew Change Edit (PROG3) revised 5/21/93 FACILITY ID 9 FACILITY NAME RECORD ID # PRIOR SWEEPS/COMP # DAIRY: Grade A — Grade B — Milk Dispenser — Number of Containers in Multi-Head Unit _ FOOD: Restaurant Market _ Commissary — Mobile Food _, Produce Stand _ Ice Plant — Seating Capacity Sq Ft Market w/Food Prep: Y / N Temporary Food Facility _ Special Food Event _ Vending Machines _ Number of Vending Units Food Vehicle _ Make License # Registration # Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE — PBR — _ HOUSING: Hotel/Motel _ No, of Units Jail/Exempt Institution Housing Abatement Employee Housing _ No. of Employees Approx Dates of Occupancy —J_/_ to LIQUID WASTE:WASTE: Pumper Vehicle — PUIRe Yard __ Chemical Toi iets — No, Package Tx Plan, _ MEDICAL WASTE: Primary Care _ Acute Care _ Skilled Nursing — Lg Generator — Sm Generator — Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) _ Transfer Sta _ Ltd Neuter _ Vet Clinic RECREATIONAL HEALTH: Poot/Spa — Number of Pools Out of Service Pool — Natural Bathing Place — t,XSP ✓SITE MITIGATION: Environ Assess UST/CALoc Haz Waste — Haz Mat PPL — Other Lead Agency Site _ Agency: RWOCS DISC — NPI. Site — RB/X20 Q — Other — _ SOLID WASTE: Landfill Transfer Sta — Recycling Fac — Waste Storage Fac _ Ag Waste/Exempt Site — SW Vehicle No. Dumpster — No. Stationary Compactor Site — VECTOR CONTROL: Poultry Farm — Max Number of Birds Kennel — EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 CONTACT 2 DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS At OF UNITS EPA ID #• INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity wilt be billed to the party identified as the BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all applicable SA JOAQUIN COON rdinince Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE / 7 Title: C)4/-�4.�Z V � , �� Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/Site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS _/_/__ SUPV _/_/_ ACCT