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10-30-1996 4: 15PM FRO'' P. 3 <br /> �tOCRAM FILE He" Cl+nnge Edit (MM3) revised 5/21193 <br /> iffy ID N FACILITY NAME <br /> ficoRD iD x SG L1,31 — -----PRtOR SUFEPS/COMP if <br /> --- --- - — <br /> DAiRYt Grade A Grade B Milk DiRpencer Nun6er of Containers in Mutti-Head Unit <br /> FOOD: Restaurant Market Mobile rood arodLxe Stand ice Plant <br /> f-- Seating Cnpaclty Sq Ft Market u/Toad Prpp: T / N <br /> T—porary Food Fecltity Special Food Event Vending Mnchirw* Nurtber of Vending Units <br /> Food Vehicle Make Llcenne N _ -�_-_ Registratlai M Color <br /> HAZARDOUS WASTE: • Tons Generated/Yr — TIERED PERMIT facility : CA CE P9R <br /> HOUSING: Note(/Motet No. of th+its Jnit/Exempt Institution Housing Abetment <br /> Employee Noosing No. of Enployee, , _r,,. ArCrer Date) of OccupancY / / to <br /> LIOUID WASTE: Ptarper Vehicle Ptr"r Yard rhoml(- <br /> al toilets No. _ PeCknge Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sat Generator <br /> Storage (2-10) _ Storage (11-SO) — Storage 50 ) Tron+fer Sts Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa NurhPr of Pools Out of Service Pool Natural sething Place <br /> _,, SITE MITIGATION: Environ Asgess UST/CAP Loc Haz UO%te He% Het PPL <br /> T� Other Lesd Agency Site Agency: RWOCR DISC NPL Site Re/H2O Q Other <br /> SOLID WAStE: Landfill Transfer Stn Rrcyctlog me Waste Storage Fac Ag Wt+*te/Exempt Site <br /> SW Vehicle No, Dts"ter No. Stationary Compactor Site <br /> VECTOR CONTROLt Poultry Farm MAX Rusty-r of 91rdn _ Kennet <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT I't Gail PattoD ( L 09) 479 - 5660 ( 209) 599, • (048 <br /> CONTACT 2 ( 200 971 <br /> DESIGNATED ENPLOTEE NI 29 - PROGRAM ELEMENT r �Q 53 CURRENT STATUS <br /> B OF UMTS _ EPA 117 9: t INSPECTION CODE <br /> 9ttLiNG end COMPLIANCE ACKNOWLEDGEMENT- 1, the tndersigned owner, operator or agent of same, acknowledge that at( alto and/or <br /> project specific PHS/EHO hourly charges associated with this facility or activity wilt be !silted to the party Identified as the <br /> BILLING PARTY on this form. I also certify that I Rave prepered this application and that the work to be performed vitt be done <br /> in accordance with ell applicable SAN JOACIUiN COUNTY Ordinance Codes and/or standards and State andlor Federal tows. <br /> APPLICANT'S SIGNATURE : eCa. t�w�ll►r <br /> Titte: < /� ` v �!/ Date: 3�/c�/ 9G Page 101; <br /> AUTHORIZATION TO RELEASE I ORMATION; In additieg to the above, when appli able, 1, the Owner, operator or agent of same, of <br /> the preperty`Located at the above site address hereby authorize the release of any and at( results, geotechnical data endlor <br /> envirormntal/site aaseasn+ent information to SAN JOACUIN COUNTY PUBLIC HEALIN SERVICES ENVIRONMENTAL HEALTH DIVISION as soot as <br /> It is ovattable and at the same time it Is provided to ate or my representative. <br /> Fee Amairtt Amount Paid Date of Payment Payment Type Receipt 0 Check 0 Recvd By <br />