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GENERAL PROGRAM FILE New Change Edit _ (PROG3) revised 5/21/93 FACILITY ID ! (0 73/co FACILITY NAME rECORD ID 0 f� —//S � PRIOR SWEEPS/COMP 9 DAIRY: Grade Al' Grade a Milk Dispenser Number of Containers in Multi-Heed Unit FOOD: Restaurant Market Commissary _ Mobile Food Produce Stand Ice Plant Seatlrq Capacity Sq Ft _ Mnrket w/rood rrep: Y / N Temporary Food Facility Special Food Event Verding Machines Number of Vending Units Food Vehicle Make License N Registratiori 0 Color HAZARDOUS WASTE: Tons Generated/Yr _ TIERED PFRHIT Facility : CA CE PBR _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement Employee Housing No. of Employees Approx Dates of Occupancy _/—/— to ,/ f LIQUID WASTE: Pumper Vehicle Purger Ynrd Chemical Toltets 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 Sta Ltd Hauler Vet Clinic RECREATIONAL HEALTH: Pool/Spa Nurrher of Pools Out of Service Pool Natural Bathing Place X SITE MITIGATION: Environ Assess X UST/CAr Loc Haz Waste Hez Met PPL Other Lead Agency Site Agency: RWOCR DiSC NPL Site RB/H20 0 Other _ SOLiD WASTE: Landfill Transfer Sts Recycling Fac Wnste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dmrmpcter No. Stationary Compactor Site VECTOR CONTROL: Poultry Form Max Number of Birds Kernel EMERGENCY NOTiFICATiONI for this FACILITY arid/or PROGRAM DAY NIGHT CONTACT 1 t Mike Wallace (City of Stockton) _ ( 209) 937 - 8628 ( ) CONTACT 2 ( ) ( ) DE§IGNATED EMPLOYEE 0 ,(f'j PROGRAM ELEMENT 0 /' CURRENT STATUS # OF UNiTS : /EPA ID 0: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be bitted 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 JOAOU(N COt TY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE /�J Title: /� 1lyG` Date: 1�-9�0 Page 10H AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or envirorraental/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 M Check N Recvd By REHS _/ / SUPV _/ /__ ACCT J //� 7 /� UNIT CLK _/ /