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M Y� <br /> CENERI►L Rr,,ail j.! s i r . , . <br /> A kil -�.rV� pACIi.'i�T� � i <br /> FACILITY-19 / �r:: / �aw <br /> RECORD 10 / �/C �Q 6 O Pit10R SWEEP!/cow ! ` <br /> _AA1RYs Orsde A Orad•• ,,„_ Milk Dispans�r,,._, .1"r of Contrinsrsyin Multi dead Unit <br /> _ FOODe Restaurant Market Commissary NOW lo food Produce !tend tee Plant <br /> !eating Capacity Sq Ft Market w/food Preps Y / N <br /> Temporary food facility Special food Event Vending Machines Number of Vending Units <br /> food Vehicle Make License N Registr•timi N Color _ <br /> HAZARDOUS WASTES Tone Generated/Yr TIERED,PERMiT Facility t CA Ct P" <br /> _ HOUSING: Notel/Notel No, of Units Joll/Exeepi institution _, Ilou•Ing Abatement <br /> Employee Mousing No. of Employees Approx Dates of Occupancy ,,/----/ to <br /> _ LIOUID WASTEs Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> _ MEDICAL WASTES Prinmary Care Acute Care Skilled Nursing 1p Generator Sm Generator <br /> Storage (2-10) i Storage (11-50) _ Storoge ( >50 ) Transfer. Ste _ Ltd Neuter _ Vet Clinte <br /> RECREATIONAL HEALTH: Pool/Sps Number of Pools Out of Service pool Nstursl lathing Place <br /> R SITE MITIGATION: Environ Assess R UST/CAP Loc Haz Waste Mez Mat PPL <br /> Other Lead Agency Site Agency: RWOCR DISC NPL Site R//H2O O Other <br /> SOLID WASTE: landfill Transfer Ste Recycling fee Waste Storage Fee Ag Waste/Exempt Site <br /> SW Vehlcte No. Dummpater No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry farm Max Number of Birds Kernel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAT MIGHT <br /> CONTACT 1's ( ) ( ) <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE s �(f S PROGRAM ELEMENT ! CURRENT STATUS <br /> ! Of UNITS s EPA iD N: INSPECTION CODE <br /> BILLING and CONK.IANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of sane, acknowledge that all site Ord/or <br /> project specific ►HS/EHD hourly charges associated with this facility or activity will be bitted w thi party-Identifled as the <br /> BILLING PARTY on this form. i also certify that I have prepared this application and that the work to bi performed will be done <br /> In accordance with sit applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards end State UL;and1 ,r�mA�JAwa. <br /> APPLICANT,'$ SIGNATURE s //l.�-s- ��%/ l ii j <br /> 1011 <br /> 2 Date: , �,� '�:.�. <br /> Title: . y� mf` 'No' e-� A <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when eppticebls, 1, the owner, operator or agent of soma, of <br /> the property located at the above site address hereby authorize the rates** of any and sit results, geotechnicst date and/or <br /> environeeental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the ssma time it is provided to me or my representative. <br /> Fee Amount raid Date of Payment Payment Type Receipt N Check N Recvd By <br /> SUPV _/ / ACCT /!�/ /7 / _ UNIT CLK _f / <br />