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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 L FACILITY iD N FACILITY NAME I _ RECORD ID N D PRIOR SWEEPS/COMP N h� DAiRYs Grade A Grade B Milk Dispenser Number of Containers In Multi-Need Unit FOOD: Restaurant Market Commissary Mobile food Produce Stand Ice Plant Seating Capacity Sq Ft _ Mnrket w/Food Prep: Y / N Temporary Food Facility Special Food Event Vending Machines Number of Vending Units Food Vehicle Make License N Registration N Color HAZARDOUS WASTES Tons Generated/Yr _ TIERED PERMIT racllity : CA CE POR HOUSING: Notel/Motel No. of Units Jail/Exempt institution Housing Abatement Employee Housing No, of Employees _ Approx Dates of Occupancy —/ / to LIQUID WASTE: Pumper Vehicle Pumper Yard _ , Chemical Tollets No. Package Tx Plant MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2.10) _ Storage (11-SO) Storage ( >50 ) Transfer Stn Ltd Hauler — Vet Cllnlc — _ RECREATIONAL HEALTH: Pool/Spa Number of Pools ____ Out of Service Pool Natural Bathing Place y �SiTE MITIGATION: Environ ��,,Assre��ss�UST/CAP Loc Haz Waste Haz Mat PPL Other Lead Agency Site Yl ".-o Agency: RWOCR _ _ DTSC HPL Site 118/11420 0 �j�Qther SOLID WASTE: Landfill Transfer Ste « Recycling Fac Waste Storage rec Ag Waste SW Vehicle No. Dumpoter No. Stationary Co/ppctaf Site V� ( 01998 VECTOR CONTROL: Poultry Form Max Number of Birds Kennel ��p �q yTRM EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY EE/VrA HFAES 1 N OIVISIpr, CONTACT 1's I )C. 571 1,'n yu n C.� ( L()A r L4knc�la CONTACT 2 ( ) ( ) DESIGNATED EMPLOYEE N 2 PROGRAM ELEMENT N a� CURRENT STATUS N OF UNiTS : EPA iD 9- INSPECTION CODE 0 `J BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, 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 will be. billed to the party Identified as the BILLING PARTY on this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all applicable SAN JOAOUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE Tette: Date: Page 1011 AUTHORIZATION TO RELEASE iNF MATION: in addition to the above, when appl able, 1, 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 stsestment information to SAN JOAOUIN 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. Z'NU O Y-7G OE Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check N Recvd By REHS /�/ VU SUP V _/__ / ii ACCi ( _/ / UNIT CLK / /