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GENERAL PROGRAM FILE New Change _ Edit (PROG3) revised 8/26J93 FACILITY IO # �d //� FACILITY NAME RECORD ID # p� yy aU �� PRIOR SWEEPS/COMP # `/ ( '�,✓ DAIRY: Grade A (" Grade B Milk Dispenser Number of Containers in Mutti-Head Unit _ FOOD: Restaurant Market Commissary 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 Vsndine Units Food Vehicle Make License # Registration # Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility CA CE POR HOUSING: Hotel/Motel No. of Units Jait/Exempt Institution Housing Abatement Enmloyee Housing No. of Employees Approx Dates of Occupancy _J_� to _ LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant M MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2-10) _ storage (11-30) _ storage ( >90 ) Transfer Its _ Ltd Hauler _ Vet Clinic RECREATIONAL HEALTH: Poo(/Spa Number of Pools Out of Service Pool Natural Bathing Place SITE MITIGATION: Environ Assess UST/CAP _ Loc Naz Waste Naz Mat PPL Other Lead Agency Site Agency: RWOC$ , DTSC NPL Site RB/H2O 0 Other SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle �_ No. Dunpster No. Stationary Compactor Site VECTOR CONTROL: Poultry Form Max Number of Birds Kernel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 . ( ) ( ) CONTACT 2 . ( ) ( ) DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS , # OF UNITS EPA ID 0: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity wilt be bitted 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 mitt be done in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANTS SIGNATURE -- s Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of sane, of the property located at the above site address hereby authorize the release of any and all results, geotechnicat data and/or envirormental/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 0 Check Al Reevd By r P UNIT CLK SUPV _/"J ACCT _�__J _J_I