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TZ /n C-n v,41 7z GENERAL PROGRAM FILE ew Change Edit (PROG3) revised 5/21/43 fACtLITY ID V�Z��7� FACILITY NAME b6PRIOR WEEPS/CaMp it ySooS� DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand tee Plant Seating Capacity Sq Ft Markat w/Focd Prep: Y / N Temporary Food Facility Special Food Event Vending Machines Number of Vending Units Food Vehicle Make Licosa S Registration S Cola' HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PSR _ HOUSING: Hotel/Notal No. of Units Jail/Exempt Institution __ Housing fitment Employee Housing No. of Employees Approx Dates of Omsupency to LIQUID WASTE: Pumper Vehicle Pu w Yard Chmicat Toilets No. Package Tx Plant ' NO[CAL WASTE: Primary Care Acute Care Skilled Nursing L9 Generator Sm Generator Storage (2-10) _ Storage (11-50) _ Storage ( M _ Transfer Ste _ Ltd Hauler _ Vat Clinic RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Foot Natural Bathing Place _ SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Mat PPL Other Lead Agency Site Agency: b= DISC NPL Site RB/1W 0 Other SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac AS Waste/Exaapt Site SW Vehicte No. Du Aster No. Stationery Campector Site VECTOR CONTROL: Poultry Farm Max Number of Birds X+ 1 EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 : C ) C—) CONTACT 2 • DESIGNATED EMPLOYEE PROGRAM ELEMENTS P �� CURRENT S7ATt� p S OF UNITS : EPA ID S: — INSAEt? BILLING and COMPLIANCE ACKNOWLEDGEMENT: t, the undersigned owner, operator or agent of $acs, ack ianldge that all site and/or project specific PRS/END hourly charges associated with this facility or activity will be billed to the party identified as the BtLLING PARTY an this fora. I also certify that I have prepared this application mid that the work to be perfonned mitt be done in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE Title: Data: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I,, the owner, operates` or agent of samme, of the property located at the above site address hereby authorize the release of arty and all results, geotechniat data and/or envirormental/site assessment information to SAM Jo=lx COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL NEALTit DIVIStCK 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 it Check S Rscvd By IREHS f SUPY �� I ACCT _�.�� UNIT CLIC