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ft FERAL PROGRAM FILE New <br /> Change Edit (PRUW) rtvised 5/21/93 <br /> ..`�N : <br /> low <br /> FAC(L1iY Io Ir �73� fACtlttt NAME <br /> RECORD 10 00 �3 PR10R SWEEPS/ <br /> • DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ r000t Restaurant Market Commissary Mobile Food Produce Stent Ie* Plant <br /> Seatirq Capacity Sq Ft Market w/food preps Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> food Vehicle Make <br /> License 0 Registration 0 Color <br /> i <br /> HAZARDOUS WASTE: Tons Generated/Tr __ <br /> TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Notel/Hotel No. of Units Jtil/Exempt Institution Housing Abatement <br /> Employee Housing <br /> No. of Esployees Approx Dates of Oeeupency _./,f to —J--f <br /> LIQUID WASTE. Pumper Vehicle Pumper Yard Chemical Toilets No. __ <br /> vaekage Tx Plant <br /> /MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lp Generator Generator <br /> Storage (2-10) ____ Storage (11-50) Storage ( >50 ) Transfer Sts d Mauler Vat Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> _ SITE MITIGATION: Environ Assess UST/CAP Loc Hat Waste NPL Site Not PPL�/N� a Other <br /> Other lead Agency Site Agency: RWCCB OTSC <br /> SOLID WASTE: landfill Transfer Ste Recycling Fee Waste store" Fac Ag Waeta/Exempt Site <br /> —— <br /> S(1 Vehicle No. Dumpste' No. Stationary Compactor Site <br /> • -. VECTOR CONTROL: Poultry Farm Max Mauer of Birds Kennel, <br /> DAY NIGHT <br /> EMERGENCY NOTIFICATION for this FACILITY ard/or PRO" <br /> CONTACT t <br /> tZO�i) 23- f i21 t ) <br /> CONTACT 2 <br /> FOEStGXMATEDMPLOYEE N <br /> PROGRAM ELE11ENT M f G` tlRMT STATUS <br /> EPA ID N. INSPECTION COOS s <br /> BILLING and ccmpLIANCE ACKNOWLEDGEMENT. I, the undersigned Owner, operator or spent of same, acknowledge that all site and/or <br /> project specific PHS/ENO hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY an this fora. I also certify that I hove prepared thio application and that the work to be performed will be cone <br /> in accordance with sit applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal. laws. <br /> APPLICANT'S SIGNATURE <br /> Oates <br /> Titles rota. or agent of sane, of <br /> AUTHORIZATION TO RELEASE INFORMATION- In addition to the above, when spplleable, I,, the osier, ape <br /> the property located at the above site address hereby authorize the release of any and all results, geotedunieal data and/or <br /> emiravwerntal/site assessment information to SAN JOIWUiM COUNTY PUBLIC HEALTH SERVICES ENVIRONPIWAL HEALTH DIVISION as soon as <br /> it Is available and at the same time it is provided to ms or my representative. <br /> Fee Amount Amount Paid Data of Payment Payment Type Receipt t Check S Raced By <br /> :� � .Vv YJ .� ✓ 4 1V� y <br /> Flu/ s>lw ^r -__� — ACCT ��96 �NiT ax <br /> RENS <br />