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GENERAL PROD WI FILE t / NewM Change Edlt (PRrevised 5/21M FACILITY ID 0 (In II FACILITY NAME RECORD 10 0 O I PRIOR SWEEPS/C" I _ DAiRTI Rlreds A Grade S Milk Dispenser Ntrber of Containers in Multi-Need Unit FOODS Restaurant Market Coeeelssary Mobile rood Produce It" Ica Plant _ testing Capacity Sq Ft Market w/food Prep: T / N Temporary food Facility _ Special Food Event Vending Machines Nutber of Vending Units Food Vehfels Make License I Reglstroticri I Color HAZARDOUS VASiE: Toro Generated/Yr TIERED PERMIT Facility : CA CE PiR ` NOUTINCt Notel/Motel No. of lknits Joll/Exempt Institution 11maing Abattarcnt Employee Rousin/ No. of Esplayees A)prox Dates of Occupancy _/ / to _ LICUID WASTE: PUtpsr Vehicle _ Pvrrer Yard Chemleal Toilets loo. Package Tx Plant MEDICAL WASTE: ►rtmary Care _ Acute Care Skilled Nursing _y_ lg Generator Sin Generator Storage 12.10) _ Storage (11-50) _ Stornge ( >50 ) Tronefer Ste Ltd Hauler Vat Clinic RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Poo( Natural lathing Piece _ SITE MITIGATION: Environ A seas USr/CAP lx Ha: Waste Na: Mat PPL 1 Other Lead Agency Sitev Agency: RLt)CRX-1, DiSC _, NPL Site Rl/1120 0 Other _ SOLID WASTE: landfill Transfer Ste _ Recycling Fac Waete Storage Fac Ag Waste/Expert Site SW Vehicle No. Dtsttnter No. Stationary Conpector Site Y VECTOR CONTRA t Poultry Fares Max Nurbor of girds Kennel EMERGENCY NOTIFICATION 1ION for this FACILITY and/or PROGRAM DAY MIGHT CONTACT 1's A)o n CONTACT 2 WICNAiEO EMPLOTEE 0 ` v I PROGRAM ELEMENT / 0�� CURRENT STA IM M /l OF UNITS t _ EPA 10 f: INSPECTION CODE IILLINO and OOMIPLIANCE ACKNOWLEDGEMENT I, the undersigned owner, "rater or agent of sone, acknowledge that all site and/or project ■pacific PNS/EMD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on this form. 1 also tify that I Ve epered this application and that the work to be performed will be done In accordance with all app! JOAOUIN TY Inane Codes ander Standards and Stats and/or Federal laws. APPLICANT' IGMATUtF t `Title: X 1"age Inn Date: AUTHORIZATION TO RELEASE iNF NATION: in addition t the above, when applicable, 1, the owner, operator or spent of sena, of the property loco*ad at the above site address hereby suthorlte the release of any and all results, geotechnsea( date and/or enVirorsaental/alta aasessatent Inforsastion to SAN JOAOUIN 07UNTY "LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It is svallable and at the sawn time it is provided to Rne or my representatlys. Fee Amount Amount Paid Data of Payarnt Payment ypo Receipt i Check IF Rtcvd By IDK SUPV _/ / [ACCT / / UNIT CLK IN � �