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i ' <br /> 'GENERAL PROGRAM FILE New Change Edit �7. (PRpG3) revised 5/21/93 <br /> f <br /> - FACILITY ID 0 FACILITY NAME <br /> RECORD ID SPRIOR SWEEPS/COMP # <br /> sow' <br /> DAIRY: Grade A r,_ Grade B Milk Dispenser Number of Containers in Multi-Head unit <br /> FOOD: Restaurant Market ,Coatmissary_ Mobi to Food _ Produce Stand_ ice Plant <br /> Seating Capacity _.;. _ S4 Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event _ Vending'liachines Plumber of Vending Units <br /> Food Vehicle ,, ..___ Make License # Registration 0 Color <br /> HAZARDOUS WASTE: Tons Generated/Tr -,�_ TIERED PERMIT Facility : CA CE POR <br /> _ HOUSING: Hotet/Motet _ No. of Units Jail/Exampt Institution Housing Abatement <br /> Eeptoyee Housing No. of Employees ApprOX Dates Of OacupancY to --- <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chamical Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skillets Nursing L9 Generator Sm Generator <br /> Storage (2.10) _ Storage (•11-50) _ Storage { a50 ) Transfer Sta _ Ltd Hauler Vet Clinic <br /> _ RECREATIONAL HEALTH: Pooi/Spa - Number of Poots _ Out of Service Pool Natural Bathing Place - <br /> SITE MITIGATION- Environ Assess UST/CAA Loc Naz Waste Max Mat PPL <br /> other Lead Agency Site Agency: KWOCO OTSC HPL Site R81112O Q r,Y„_ Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac A9 Waste/Exempt Site <br /> _..__ SW Vehicle No. ., Dumpster No. _ Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds _— Kemet <br /> EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAM DAY NIGHT <br /> CONTACT i : Jay Zimmerman (209 } 331-Z-12- <br /> CONTACT <br /> 31-7-169 CONTACT 2 . Frank Biglow 2 c� 331-7,200 <br /> DESIGNATED EMPLOYEE # `� PROGRAM ELEMENT # J CURRENT STATUS I S <br /> g OF UNITS EPA ID 0: INSPECTION CODE --- _ <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that Bit site andlor <br /> proiect specific PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also ertify that I have prepared this application and that the work to be performed watt be done <br /> in accordance with all a obt J COUNTY Ordinance Codes and/or Standards And State and/or Federal laws. <br /> APPLICANTtS SIGNATURE <br /> Title; Administrative Di ct r of Faci 1 ' Date: <br /> AUTHORIYATION TO RELEASE INFORMATION; In addition to 04 ";'IMen appileabte, 1, 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 date and/or <br /> environmental/site assessment information to SAN 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 /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> p��Jf 3 1p 30 13103 <br /> RENS _!_J SUPV / � ACCT j UNIT CLK <br /> TOTAL P.03 <br />