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v-"kL PROGRAM FILE New _ X Change Edit (PROG3) revised 5/13/93 FACILITY ION NEW FACILITY NAME ��r RECORD t0 N PRIOR SWEEPS/CCNP N 7C-Yt F-W 7,, oY _ DAIRY: Grade A Grade B Milk Dispenser Nunber of Containers in Multi-Head Unit FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant Food Vehicle Make License N Registration N Color Seating Capacity Sq Ft Market w/food Prep: Y / N N of Vending Machines HOUSING: Hotel/Motel No. of Units Jail Employee Housing No. of Employees _ LIQUID WASTE: Pumper Vehicle Punper Yard Chemical Toilets No. Package Tx Plant RECREATIONAL HEALTH: Pool/Spa Nusber of Pools Out of Service Pool Natural Bathing Place _ SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Hax Mat PPL Other Lead Agency Site__ Agency: RUQCS DTSO Upt Site � RS/u20 Q Other SOLID WASTE: Landfill Transfer Sts Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dunpster No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY - CONTACT 1 C ) C ) CONTACT 2 : C ) C ) DESIGNATED EMPLOYEE N PROGRAM ELEMENT N 6 - CURRENT STATUS EPA IO N: Approx Occupancy Dates _/ / to 4L'M8ER OF UNITS INSPECTION CODE BILLING ACXNCWLEOGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY an this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE ~y'/ Title: 4-7V�/ Date: ... ;' AUTHORIZATION TO 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 all results, geotechnical data and/or envirormentat/site assessment information to SAN JOAQUIN 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 N Check N Recvd BY 00.00 RENS J ��' //-3 ACCT UNIT CTK _ J r_..._.........