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GENERA PROGRAM FILA New Chnnge Edit (PROG3) revised 5/21/93 FACILITY ID M b b 7'fI Q FACILITY NAME RECORD 10 0 Y I PRIOR SWEEPS/COMP N _ DAiRY: Grade A Grade 8 Milk Diepenser Ntrrber of Containers in Multi-Head Unit _ FOOD: Restaurant Market Commissnry _, Mobile rood Produce Stand Ice Plant ^_ Seating Capacity sq Ft Market w/Food Prep: Y / N Temporary Food Facility Special Food Event _` Vending Machines Nurber of Vending Unita Food Vehicle Make License M Registration M Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PFRMIT Facility : CA CE FOR _ HOUSING: Hotel/Motel No. of Units Jail/Exeapt institution Housing Abatement Employee Housing No, of Employees _ _ Arprox Dates of Occupancy _/ / to _ LIOUiD WASTE: Pumper Vehicle Purger Yard _ Chemical Toilets No. Package Tx Plant - MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2-10) Storage (11-50) Storage ( >50 ) Transfer Ste _ Ltd Hauler Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa NLr+er of Pools Out of Service Pool Natural Bathing Place V1 SITE MITIGATION: Environ Assess UST/CAP Loc Ilaz Waste _ Haz Hat PPL Other Lead Agency Site Agency: RWOCR __ DISC VasNPL Site RB/1120 0 Other SOLiD WASTE: Landfill Transfer Ste Recycling Fee Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Ourpster No. Stationary Compactor Site VECTOR CONTROL: Poultry Form Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1': 76-5 EAlyi"momxtrRL�iNC. fKYG,f- /cczY, - /`00 (¢✓5 )8S9 /400 CONTACT 2 ¢iS-) 783 -y9vc3 (�hS) 799 - 0900 DESIGNATED EMPLOYEE / _Lk PROGRAM FLFMENT ! CURRENT STATUS OF UNiTS EPA ID 0: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/END hourly charges associated with this facility or activity will 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 performed will be done In accordance with ell applicable SAN JOAOUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. s / APPLICANT'S SIGNATURE �l �/�S/ N/ N77yC�/,VC- 44 / / y Page 1011 Title: Date: AUTHORIZATION TO RELEASE FORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of the aroperty'located at the abcvF site address hereby authorize the release of any and all results, geotechnical data and/or environnental/sizt assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is evalleble and at the sante time it is provided to me or my representative. Fee Amount Amount Pald Date of Payment Payment Type Receipt M Check N Recvd By RENS / - SUPV i ACCT UNIT CLK _/ /