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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID e 8 FACILITY NAME <br /> RECORD ID ! ' PRIOR SWEEPS/COMP R — <br /> _ DAIRY: Grade A _ Grade S Milk Dispenser _ Number of Containers in Multl-Heed Unit <br /> FOOD: Restaurant _ Market Commissary __ Mobile Food _ Produce Stand _ Ice rinnt <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility _ Special Food Event _ Vending Machines _ Number of Voiding Units <br /> Food Vehicle _ Make License K Re0(stratioi M Color <br /> HAZARDOUS WASTE: ^ Toro Generated/Yr _ TIERED PERMIT Facility : CA _ CE __ PBR _ <br /> _ HOUSING: Hotel/Motel _ No. of Units Jail/Except Institution Housing Abatement <br /> Employee Housing _ No. of Employees Approx Dates of Occupancy _/_/_ to ^/_�_ <br /> LIQUID WASTE- Pumper Vehicle _ Pieper Yard ^ Chemical Toilets — No. Package Tx Plant _ <br /> _ MEDICAL WASTE- Primary Care _ Acute Care _ Skilled Nursing ^ Ig Generator _, Sm Generator _ <br /> Storage (2.10) _ Storage (11-50) _ Storage ( 150 ) Transfer Ste _ Ltd Hauler _ Vet Clinic _ <br /> RECREATIONAL HEALTH- Pool/Sps _ Number of Pools __ Out of Service Pool _ Natural Bathing Place _ <br /> X SITE MITIGATION: Environ Assess UST/CAP _ Loc Hex Waste X Net Mat PPL _ <br /> Other Lead Agency Site _ Agency: RWOCR X DTSC _ NPL Site ^ Re/1120 0 _ Other _ <br /> _ SOLID WASTE: Landfill Transfer Ste _ Recycling Fee _ Waste Storage Fac _ Ag Waste/Exempt site <br /> SW Vehicle _ No. Dtsepeter _ No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm _ Max Numbr of Birds Kennel _ <br /> EMERGENCY NOTIFICATION for this FACILITY aril/or PROGRAM DAY NIGHT <br /> CONTACT 1 t John Guzman ( 209) 982-2093 <_) <br /> CONTACT 2 : Scott E. Gable ( 510) 866-6244 <_) <br /> DESIGNATED EMPLOYEE S PROGRAM ELEMENT g CURRENT STATUS <br /> N OF UNITS : EPA ID A: 21 % INSPECTION CODE <br /> BILLING and CONK IANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that sit site end/or <br /> project specific PNS/EHD hourly charges 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 applfcation and that the work to be performed will be done <br /> In accordance with all applicable SAN JOAQUIN COUNTY Ordinance �codes and/or Standards and State and/or Federal Laws. <br /> APPLICANTtS SIGNATURE I_ ✓v �' <br /> IV <br /> Title- Project Manager Date: February 19, 1997 Fake 1011 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the prcperty'located at the above site address hereby authorize the release of any and all results, geotechnfeat data and/or <br /> envirormentsl/aha assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION es soon as <br /> it is available and at the same time It Is provided to me or my representative. <br /> Fee Ameotnt Amount Paid Date of Payment Payment I Receipt N Check M Recvd By <br /> t; <br /> � <br /> EHSIW/�✓/ 1 SUPV _/_/_ ACCT �, oa/ a UNIT CLK �_/_ <br />