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02-22-1996 03:59PM FROM�/[\ TO 14158762452 P.03 <br /> ` /AOORAN FILE New I Change Edit �T P)[OG3) revised 5/21/03 <br /> 4 r. <br /> TY 10 ! i7S rJ-�/� FACILtTT LARNE <br /> K <br /> ECOND ID ! �i �� PRIOR SWEEPS/COMP ! <br /> DAIRYI Grade A Orae B Milk Dlopenser Number of ContaineraFl� <br /> FOODt Reeteuratit Market Commissary Mobile Food Produce Stand _ .fee Piens <br /> Seating Capacity Sp Ft Mnrket w/rood rrepe T / N <br /> Temporary Food reelltt;_ special Food E..nt Ven)Im4 Machines __ Number of Vending Units <br /> Food Vehicle I Make Llcenso Y Realstratioi Y Color <br /> HAZAROWS WASTE: i •- Tons Generated/Yr _ TIERED PERMIT reellity r CA CE FOR <br /> HOUSING: Notel/Metal No_ of lhmlts Jolt/Exempt Institution Housing Abutment <br /> Employee Nousing�_ No. of Employees Arrox Dates of Occupancy `/_/� to <br /> LIQUID WASTE: IPt rper Vehicle Pamper yard _ Ci...mical Tollets No. Package To Plant <br /> I <br /> i <br /> MEDICAL WASTE; Crlmery Care _ Acute Cnre Skilled Nuraing Lg Generator Sm Generator <br /> Storage (2-10) 1 Storage (11.50) ____ Storage ( >50 ) Transfer Ste _ Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH- Pool/Spa NlTrber of Pools Out of Service Pool Natural Bathing Piece <br /> SITE MITIGATION: EnvironAsseSs X UST/CAP Loc Has Waste Net Met PPL <br /> other Lead Agency Site ^ Agency: RWOCR vise _ NPL Site — RB/1120 0 _ Other <br /> _T SOLID WASTE: Landfillmp <br /> Transfer Stn _ Recycling nae Waste Storage Fee _ Ap VaAte/Exet Site <br /> SW Vehicle _ Mo. Dampeter No. Stationary Compactor Sita <br /> i <br /> VECTOR CONTROL: (Poultry farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY MIGHT F <br /> CONTACT 1 'ITL <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE I,! �jL (2 PROGRAM ELEMENT ! a 7 S b CURRENT STATUS <br /> I <br /> Y OF UNITS : EPA ID !t INSPECTION CCDE 30c) <br /> BILLING and CO(PL IANCE� ACKNOWLEDGEMENT: I, the Undersigned owner• operator or agent of same, acknowledge that all site and/or <br /> project speelfle PNS/END hourly chargee associated with this facility or activity will be bitted to the party Identified as the <br /> BILLING PARTY on this �Iorm. 1 also certify that 1 have prepared this application and that the work to be performed will be done <br /> In occordwiee with sill applicable SAN JOAOUIN COUNTY Ordinance Codes end/or Standards and State and/or Federal laws. <br /> - ,_ <br /> APPuuwr•s sieNATURE-�–' ��!,C���Z�!( rJY <br /> Title: /alt fid'_ v 1'oKe 1//!l <br /> N Date: -. �-,• ( , <br /> AUTHDRIZATION T— RELEASE PORHAT10Mr In addition to the above, when epptiesble, 1, the owner, operator or agent of same, o1 <br /> the prtperty'loca ted of o <br /> the above site address hereby, authorize the release of any and all results, geotechnical date wd/or <br /> envirorfoentol/Sita aaeeaaent Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROMENTAL HEALTH DIVISION as soon as <br /> It is available and s0he sanot time It Is provided to me or my representative. <br /> fee Amant t--Paid Data of Payment Payment Type Receipt Y Cheek 0 Recvd By <br /> �a3 _ �a3f - �231gC, Yaoo1sSS <br /> SUPV ACCT UNIT CLK <br />