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GENERAL PROGRAM FILE New Chnnge Edit (PROG3) revised 5/21/93 FACILITY ID N �J 02 FACILITY NAME RECORD ID N J� PRIOR SWEEPS/COMP N _ DAIRY: Grade A Grade a Milk Dispenser Number of Containers in Multi-Head Unit FOOD: Restaurant Market Comnissnry Mobile food Prodr-roe Stand ice Plant _ Seating Capacity Sq Ft Mnrket w/Food Prep: Y / N Temporary Food Facillty Special Food Event _ Vending Mnchines Number of Vending Uri Ita Food Vehicle Make License N Registration N Color HAZARDOUS WASTE: - Tons Generated/Yr TIERED PERMIT Facility : CA CE POR _ HOUSING: Hotel/Motel No. of lhiits Jnil/Exempt Institution Housing Abatement Employee Housing No. of Employees _ Approx Dates of Occupancy _/ / to LIQUID WASTE: Pumper Vehicle Purper Yard _ Chemical Toilets No. _ Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Cnre Skilled Nursing Lg Generator Sm Generator Storage (2-10) Storage (11-50) Stornge ( >50 ) Transfer Stn _ Ltd Hauler Vet Clinic - RECREATIONAL HEALTH: Pool/Spa Nurher of roots __- Out of Service Pool Natural Bathing Place _ SITE MITiGATION: Environ Assess UST/CAP _ Loc Haz Wmste Haz Met PPL Other Lead Agency Site Agency: RWQCR DiSC NPL Site RB/1120 Q Other _ SOLID WASTE: Landfill Transfer Ste Recyclinq me Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Drmpater __ No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Ntml3or of Birds KerxeI EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 t U iUG �AT� CONTACT 2 : J a N,.l Lvy (SIC ) 82f DESIGNATED EMPLOYEE 0 rROGRAM ELEMENT N a I CURRENT STATUS N OF UNiTS EPA ID N: INSPECTION CODE BILLING and COMPLIANCE ACKNCULEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific PHS/EHO 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 have prepared this application and that the work to be performed will be done in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANTS SIGNATURE �c �� 1 1�1(�1� I`C ,Mr2� ��L lV4�jU�2t I'(/ge 101; Title: Date: AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of .F.e preperty loc tod at t.".ii Bove site address hereby authorize the release of any and all results, geotechnical data end/or envirormentat/site• assessment information to SAN JOAQUIN 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. Fee Amant Amount Paid Date of Payment Payment Type Receipt N Check * Recvd By � �3 Ll r gay z 6 7 RENS _/ / SUPV ACCT 7/ a_/ UNIT CLK _/ /