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GENERAL PROGRAM FILE New Clisnge Edit (PROG3) revised 5/21/93 FACILITY 1D N 'L/ -3 FACILITY NAME RECORD ID 0 Q� �D PRiOR SVEEPS/COMP R _ DAiRY: Grade A/ Grade a Milk Dispenser Nurber of Containers in Multi-Head Unit FOOD: Restaurant Market Comnissary _ _ Mobile rood Produce Stand Ice Plant Seating Capacity Sq Ft _^ Market w/food rrep: Y / N Temporary Food Facility Special Food Event Vending Machines Nurber of Vending Units Food Vehicle Make License N Registration M Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PFRMIT Facility : CA CE POR _ HOUSING: Hotel/Motel No. of Units Jail/Exempt institution Housing Abatement Employee Housing No. of Employees Approx Dates of Occupancy _/-/- to LIQUID WASTE: Pumper Vehicle Purrper Yard _ Clromlcal Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2-10) _ Storage (11-50) Storage ( >50 ) Transfer Ste _ Ltd Hauler Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa NLmhef of Pools _^ Out of Service Pool Natural Bathing Place X SITE MITIGATION: Environ Assess X UST/CAr _ Loc Ilaz Waste Haz Mat PPL Other Lead Agency Site Agency: RWOCR DTSC HPL Site RB/H20 Q Other _ SOLID WASTE: Landfill Transfer Ste Recyc(inq Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dumpater No. Stationary Comp)gtrf Site 4196 VECTOR CONTROL: Poultry Form Max Number of Birds Kennel Aly ,�;HULr n! Pito EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAM DAY �:N/1RC,N �TALI�LiGH1 CONTACT 1 t Mr. Steve Peterson _ ( 209 ) 546-8249 (209 ) 956 9584 CONTACT 2 ( ) - ( ) DEtIGNATED EMPLOYEE 9 PROGRAM ELEMENT 0 ` j(� CURRENT STATUS / OF UNITS EPA ID 0: (/ INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific PHS/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 1 have prepared this application and that the work to be performed will be done In accordance with all applicable SAN JOAQU N COUNTY ordinance Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE �/ �Z1/C�/ y/ ,(,f;C' ��1; Title• Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property'I oca ted at the above site address hereby authorize the release of any and all results, geotechnical date and/or environmental/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 Amount Amount Paid Date of Payment Payment Type Receipt 0 Check K Recvd By RENS / / SUPV / / ACCT / / UNIT CLK / /