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' GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY• ID 0 �d l r� FACILITY NAME -- U, J "T�/ v <br /> - <br /> RECORD IDy PRIOR SWEEPS/COMP <br /> DAIRY: Grade A Crede 8 Milk Dispenser Number cf Containers in Multi-Heed Unit <br /> FOW: Restaurant Market Commissary _— Mobile rood produce Stand rte, <br /> Seating Capacity Sq Ft _ Market u rood Preps Y / N I� <br /> Temporary Food Facility Special Food Event -- Vendtr_ Mnchlnes Number of Vend) is L`Cf <br /> Food Vehicle Make License 0 Reglatratiori N Cv(or <br /> ----.� JUN 2 0 1997 <br /> HAZARDOUS WASTE: -- Tons Generated/Yr TIERE� PFRMIT racitity CA CE POR <br /> ENVRONMENTAL HEALTH <br /> _ HOUSING. Hotel/Motel No. of Units JRit/EXenpt Institution Housing AbatK"94MVICES <br /> Employee Housing No. of Employees Approx Dateg of Occupancy ! / to <br /> LIoUID WASTE: Pumper Vehicle Purper Yard Chrmicat Toilets No. ' Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Cnre Skilled Nur Ing Lg Generator Sm Generator <br /> Storage (2-10) Storage (11-50) Storage ( X50 > Tronofer Stn r Ltd Hauler Yet Clinic <br /> RECREATIONAL HEALTH; Pool/Spa Number of Poo($ 0> t of Service Pool Natural Bathing Piece <br /> X SITE MITIGATION: Environ Assess UST/CAP X Loc Haz was a Hai Hat PPL <br /> other Lead Agency Site Agency: RWoCA DISC NPL Site RB/H20 0 Other <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dun"ter No� Stationary Coapactor Site <br /> i <br /> VECTOR CONTROL: Poultry Form Max Number of Birds Kennet <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY may} NIGHT <br /> CONTACT 1 s MIKE GALLAGER O <br /> CONTACT 2 : GOODMACHER 1760 ) 746-4955 ( 769 746--4955 <br /> DOIGNATED EMPLOYEE N PROGRAM ELEMENT * -sf CURRENT STATUS rv�,Gc1 <br /> 0 OF UNITS ! EPA ID 0., INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, opera or or agent of same, acknowledge that all site and/or <br /> project specific PHS/EMO hourly chargee associated With this facility or activity will be billed to the party Identified as the <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done <br /> In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or St a ds and State aril/or Federal laws. <br /> APPLICANTS SIGNATURE : � <br /> Titre: lleM4gZ 4• C.�irT� d t14 AVIV-. � �`�T Page 1011 <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when eplis e, [, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the rete se of any and all results, geotechnical date and/or <br /> envirormentat/stte assespment information to SAN JOAQUIN COUNTY PUBLIC H ALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the same time it Is provided to me or nmy represen ative. <br /> Fee Amount Amount Paid Date of Payment Payment T pe Receipt 0 Check * Recvd By <br /> - -F7 Z2L <br /> RENS ! /7-7 rZ SUPV ! — ACCT 41 ;b !?, 4 UNIT CLK �/ 1 <br /> — --- _, <br />