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09-20-1993 11:45AM FROM TO 15775792 P.04 �E^NERAL PROGRAM FILE New Change Edit (PROG3) revised 5121/9; a Ft,JILITY,ID # 1 _� FACILITY NAME RECORD ID # C� �/) ' PRIOR SWEEPS/COMP # r r DAIRY: Grade A Grade a Milk Dispenser Nud*r of Containers in Mutti-Head Unit FOOD: Restaurant Market Comissary Mobile Food Produce Stand ice Plant Seating Capacity Sq Ft Market w/Food Prep: Y / N Temporary Food Facility Special Food Event vending Machines Number of Vending Units Food Vehicle Make license # Registration # Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE POR HOUSING: Hotel/Motet No. of Units Jail/Except Institution Housing Abatement Employee Housing No. of Employees Approx Dates of occupancy / J to LICUID WASTE: Pumper Vehicle _____ Pumper Yard Chemical Toilets No. Package Tx Plant MEDICAL WASTE: Primary Care Acute Care SkiLlad Nurzing � Lg Generator Sim Generator Storage (2-10) _ Storage (11-50) _ Storage { >50 ) _ Transfer Sta _ Ltd Hauler _ Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa Number of PpoLs Out of Service Pool Natural Bathing Place XX SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Mat PPL Other Lead Agency Site Agency: RWCCB _j DTSC NPL Site RS/H20 0 _____ other SOLID WASTE: Landfill Transfer Sta __ Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dumpster No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 Doug Ohland (209 ) 577 - 5721 ( 209 524 . 7869 CONTACT 2 : Lupe An&el _. (209 ) 577 - 5721 (-20$ 575 - 9666 DESIGNATED EMPLOYEE # 71 PROGRAM ELEMENT # x o CURRENT STATUS # OF UNITS EPA ID #: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or prola-t specific PHS/EHD hourly charseS associated with this facility or activity witL be billed 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 perforeaed will be done in accordance with all appL'a�e SAN JOAQUIN COUNTY Ordi)30PXICodes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE Title: / I Date: AUTHORIZATION TV RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and alt results, 9ectechnical data and/or environmental/site assessment infornation to SAN JOAOUIN 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 # Recvd Sy REHS /"L?/ 3 SUPV ��Tf ACCT T/,T/ UNIT CLK TOTAL P.04