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r GtNERAL PROGRAM FILE New Chnoge Edit (PROG3) revised 5/21/93 —r - rFACILiTY ID N /a/JL�G FACILITY NAME I „NQS S- o Di p.',{02F11 RECORD 10 N /� �//_ /1 PRIOR SWEEPS/COMPO DAIRY: Grade Al, Grade O Milk Dispenser Number of Containers in Multi-Heed Unit FOOD: Restaurant Market Commissary _, Mobile Food Produce Stend Ice Plant Seating Capacity Sq Ft _`- Mnrket w/rood rrep: Y / N Temporary Food Facility Special Food Event Vending Machines Nurber of Vending Units Food Vehicle Make License N _ A — Registration N Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE FOR _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement Employee Housing No. of Employees _ Approx Dates of Occupancy —/—/— to _ LIOUID WASTE: Pumper Vehicle Pumper Yard _ Chemical Toilets 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 Ste Ltd Hauler Vet Clinic RECREATIONAL HEALTH: Pool/Spa Ntr+,tr of mals -___ Out of Service Pool Natural Bathing Piece SiTE MITIGATION: Environ Assess — UST/CAr Loc liaz Wnste Haz Mat PPL Other Lead Agency Site Agency: RWOCR DISC HPL Site RB/1-120 0 Other _ SOLID WASTE: landfill Transfer Stm _ Recyclinq me Wnste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Otsrrpater No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Mnx Nrmtr:r of Blnds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 't re 0<—:1 rr Ci OC)D ( ) CONTACT 2 rGC DE§IGNATED EMPLOYEE R i 9 PROGRAM ELEMENT N CURRENT STATUS w OF UNITS EPA ID A': INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PMS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. i also certify that I hnve prepared this application and that the work to be performed will be done In accordance with all applicable SAN JOAOUIN COUNTY Ordinance Codes end/or Standards and State and/or Federal laws. LO S Ce,3,.c v%-A rr n L4ro r e S o-F APPLICANT'S SIGNATURE i r Lo e-- Title: Pl cQev�,�' Date: ��Clx(' 1011re AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of (SaaK`,r�f ,he property located at tie abevq site address hereby authorize the release of any and all results, geotechnlc�l��CC►irrhtra drid/o—n environmental/site atsestment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DTF}S-FbH'tfsysoon as It is available and at the same time It is provided to me or my representative. Qu Fee Amount Ammnt Paid Date of Payment Payment Type Receipt k Check N Recvd ByvubS N'1' dIS10N 4:.. RENS ( , / / SUPV / / ACCT / / UNIT CLK / /