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DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Multi-Head Unit <br />(Z) 4f'4. 422-7— <br />(7/7 1 ) e-,e,3 <br />Mee "9777/CMS` P/77 ,17 <br />iSW e e 74yr <br />CONTACT 1 : <br />CONTACT 2 : <br />/77/0c <br />GENERAL PROGRAM FILE : New <br /> <br />Change Edit <br /> <br />(PROG3) revised 5/21/93 <br /> <br />FACILITY ID # FACILITY NAME 2-.1 7/-6? 7.--X 1 /4-',../' 75, -.G //ç STre it zt:// <br />RECORD ID # eK,505-330 PRIOR SWEEPS/COMP # <br />FOOD: Restaurant Market Commissary Mobile Food <br /> <br />Produce Stand Ice Plant <br />Seating Capacity Sq Ft Market w/Food Prep: Y / N <br />Temporary Food Facility Special Food Event <br /> Vending Machines Number of Vending Units <br />Food Vehicle Make License # <br /> <br />Registration # Color <br />HAZARDCUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE <br /> <br />HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br />Employee Housing No. of Employees Approx Dates of Occupancy to <br />LIQUID WASTE: Pumper Vehicle Pumper Yard <br /> <br />Chemical Toilets No. <br />MEDICAL WASTE: Primary Care Acute Care <br />Storage (2-10) Storage (11-50) Storage ( >50 ) Transfer Sta <br />RECREATIONAL HEALTH: Pool/Spa Number of Pools <br />ti./aL 06=_5-/-7ew e;i7e..%/v <br />;/,' SITE MITIGATION: Environ Assess 4 UST/CAP Loc Haz Waste <br />Other Lead Agency Site Agency: RUOCB \/ DISC <br />Skilled Nursing Lg GenerR <br />Out of Service <br />NPL <br />hieV °r CL <br />Ltd Hauler Vet C inic <br />J L -7-7 1994 <br /> <br />Poo l E-PP9LI RlIttiPLEMrAl.?tL <br />Haz Mat PPL PERMIT/SERVICES <br />Site RB/H20 Q Other <br />Package Tx Plant <br /> <br />SOLID WASTE: Landfill Transfer Sta Recycling Fac <br /> <br />SW Vehicle No. Dumbster <br />Waste Storage Fac Ag Waste/Exempt Site <br />No. Stationary Compactor Site <br />VECTOR CONTROL: Poultry Farm Max Number of Birds <br /> <br />Kennel <br />EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM <br /> <br />DAY <br />DESIGNATED EMPLOYEE N 261 to D PROGRAM ELEMENT # CURRENT STATUS <br /># OF UNITS : EPA ID #: INSPECTION CODE : <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br />project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br />BILLING PARTY on this form. I also certify that 'have prepared this application and that the work to be performed will be done <br />in accordance with all_a licable.SAN JO TY Ordinance Codes and/or Standards and State and/or Federal laws. <br />APPLICANT'S SIGNATURE : ( Pin 4 /e0 A.) <br />Title: Date: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same time it is provided to me or my representative. <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />Cif -et t:oPr'e' - f.lociivz," <br />e)44,7.17A_ <br />REHS /g 1 SUPV / / <br />, 44z <br />UNIT CLK ACCT