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GENERAL PROGRAM FILE New i Change Edit .. .. CPRWd)'rwi&ad 8/26/93 <br /> FACILITY ID / O <br /> FACILIT <br /> OD� 3 Y NAME �'�F`^'' /P► j <br /> RECORD to # PRIOR'SWEEPS/C01tP <br /> DAIRY: Grade A Grade 11 .Mill[ Der� " Number of Containers,in Multi Need Unit <br /> a <br /> MIS, <br /> y�•ry,SL <br /> t-i} ia: <br /> FOOD: Restaurant Market Commissary' Mobile Food Produce Stand':* 'ice Plant :4 <br /> Seating Capacity Sq Ft a'X Market wlFaod Prep: T <br /> R,.'ki <br /> T«+porary Food Facility Special Food Event Verdirq Machines mow ' Number of Vandine Unita F` <br /> Food Vehicle Make License # ,Registration. <br /> HAZARDOUS WASTE_: Tans GeneratedlYr TIERED TPERM[T Facility G ""a CE 'i* PBR l <br /> HOUSING: Hotel/Motel No.of Units 1Ail/Exeapt'tnstitution Housing Abstement.• <br /> Emptoyee Housing No. of Employees Approx Dates of Occupancy <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard. #i .1Chemical Toilets No. Package Tx Pien! <br /> MEDICAL WASTE:. Primary Care r Acute Cart Skitled Nursing' Lg Generates <br /> Storage (2-10) _ storage (tt-SIZ) steragf.( *90 ) Transfer Ste Ltd Hauler :-Vet C:Lin1c`. <br /> j' <br /> RECREATIONAL HEALTH: Pool/Spa Number of Poo:Es Out of,Service Pool Natural Bathing Place <br /> A:::j'STTE MITIGATION: Environ AssessagS__ UST/CAPLoc Raz Waste Jt Naz Mat PPt _ <br /> Other Lead Agency Site Agency: RUCC8 DISC i NPL Site RB/H2O 0 Other . <br /> _ SOLID WASTE Landfill Transfer Sta Recycling Fac haste Storage Fac Ag Waste/Exempt-Site <br /> SW Vehicte No. Dumpster. No. Stationary.Conpector. Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMEEGEI+CY NOTIFICATION for this. FACILITY and/or PROGRAM DAY µ NIGHT. <br /> C1311TACT 1 <br /> CONTACT 2 ( ) ) <br /> r <br /> DESIGNATED EMPLOYEE # O 8 PROGRAM ELEMENT.# vl•�, CURRENT STATUS <br /> It OF UNITS EPA Io #: INSPECTION ME <br /> BILLING aiid COMPLIANCE ACKNOWLEDGEMENT: 1, .the undersigned owner, operstor.or agent of same, acknowledge that all site and/or.. <br /> prof-et .specific IkNS/EHC howl clSar3ts.:asscsiatcd,mi- —this fxii{ty.or actiy;t,LIIt be leI4e to Lhe pert I— If.led as the <br /> BILLING PARTY on this form. I'.atso certify that I have prepared this sMcfeation and that the work to be perforeied will be done -='r <br /> in accordance Frith all applicable SAN dOAOUIN COUNTY Ordinance Codes and/or Stardar� State and/or ray I <br /> APPLICANT'S SiGNATURi?1: <br /> IV <br /> Data: <br /> Title: � /NT � � - <br /> AUTHORIZATION TO RELEASE INFORMATION: ]n addition to the above, when applicable, I, the Ob~ operator or:agent of same. of <br /> the property located at the above site address hereby authorize the release of wry and all r0wits, iC&I data and%or <br /> enrvironmentat/site assessment information to-SAN jcMIN COUNTY PUBLIC WEALTH SERVICES ENVIROM ENTAL TR as <br /> it is available and at the same time it is provided to me.or W representative. <br /> Fee Amamt Amount Paid onto of Payment.' Payment Type Receipt # Cha*, <br /> >tiaekc B- ReaW By <br /> _4,37,0. oe <br /> REIMS '�/ � stlPv /�J ACCT �J_� UNtT CLIC �f�.J <br />