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GENERAL PROGRAM FILE ,iNe(u) .� Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID s 1 �L4-y� --- FACILITY NAME <br /> RECORD ID M l LCI PRIOR SWEEPS/COMP R <br /> DAIRY: Grade A _ Grade B _ Milk Dispenser Nunber of Containers in MULCI-Head Unit <br /> _ FOOD- Restaurant _ Market Caemisssry Mobile Food _ Produce Stand _ fee Plant <br /> Seating Capacity Sq Ft ^ Market u/Food Prep: Y / N <br /> Temporary Food Facility _ special Food Event — Vending Machines _ NLaber of Vending Units ' <br /> Food Vehicle _ Make License M T Re0 stratioi M Color <br /> HAZARDOUS WASTE: Tons Generated/Yr _ TIERED PERMIT Facility : CA _ CE _ PBR _ <br /> _ HOUSING. Notal/Motet _ No. of hits Jnil/Exeapt Institution Housing Abatement <br /> Eaployea Housing _, No. of Employees Approx Dates of Occupancy _/_/_ to _/—�— <br /> LIQUID WASTE. Pterpr Vehicle __ Puaper Yard Chemical Toltete __ MO- Package ix Plant _ <br /> _ MEDICAL WASTE: Prfinery Care _ Acute Care skilled Nursing _ Lg Generator _ Sm Generator _ <br /> Storage (2-10) _ Storage (11.50) _ Storage ( 150 ) Transfer Ste _ Ltd H er _ Vet Clinic <br /> _ /RECREATIONAL HEALTH: Pool/Spa Nurber of pools Out of Service Pool _ Natural Bathing Place <br /> / SITE MITIGATION: Environ Assess e"" UST/CAP Loc Nez Waste Haz Met P L , <br /> Other Lead Agency Site _ Agency. RWOCR _� DISC ✓ NPL Site RB/H2O 0 _ Other _ <br /> SOLID WASTE- Landfill Transfer Ste Recycling Fee _ Waste Storage Fee _ Ag Waste/Exempt Site <br /> SW Vehicle _ No. ourpater ,_ No. Stationary Coapactor Site _ <br /> _ VECTOR CONTROL: Poultry Farm _ Max Nuaber of Birds Kernel <br /> EMERGENCY NOYiF1CATI0N for this FACILITY and/or PROGRAM <br /> DAY NIGHT <br /> COH7ACi 1 -t <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE s n PROGRAM ELEMENT / t/ / �- CURRENT STATUS <br /> M OF UNITS : EPA ID S: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: t, the undersigned owner, operator or agent of smie, acknowledge that all site and%or <br /> project specific PNS/END hourly chargee associated with this facility or activity will be billed to the party Identified as the <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performld will be done <br /> In accordance with all applicable AN JOAQUI/N'�COUNTY Ordinance Coder Standards and State artd/or Federal laws. <br /> APPLICANT'S SiONATURE : 4/1.- -O� 6— <br /> /e aC( 1 !!!j l- /�a, Ali' 7 Page 1011 <br /> Title: a R+v ITi QG Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In adds ion to the above, when applicable, 1, the owner, operator or agent of sane, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> anviroreentat/site eaaessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same elms It Is provided to me or my representative. <br /> Fee Amxxmt Amount Paid Date of Payment Paynent Type Receipt M Check N Recvd By <br /> r NC2 gz,T°O j 5� C� 6�16�� lug <br /> PENS 1� APV / / ACCT / / UNIT CLK <br />