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GENERAL PROGRAM FILE New Change _ _ Edit _ (PROG3) revised 5/21/93 <br /> FACILITY ID 0 FACILITY NAME <br /> RECORD ID N �J�/ r,�/�72 Ce' PRIOR SWEEPS/CORP N <br /> DAiRY: Grade A Grade 8 Milk Dispenser ___ Nurber of Containers in Multi-Head Unit — <br /> _— FOOD: Restaurant Market Commissnry ___ Mobile rood Produce Stand Ice Plnnt _ <br /> Seating) Capacity Sq Ft _— _ _- Mnrket w/rood Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License N Realstratiori N Color <br /> HAZARDOUS WASTE: Tons Generated/Yr – TIERED PFRHIT Fatuity : CA CE PBR <br /> — HOUSING: Hotel/Motel No. of Units Jnil/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees __-- _ Approx Ontes of Occupancy _/—I— to <br /> _ LIQUID WASTE: Pumper Vehicle Pumper Ynrd Chronical Tollets —_ No. _ Pnrknoe Tx Plant <br /> — MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-SO) Stornge ( >50 ) _ Transfer Stn Ltd Hauler Vet Clinic <br /> _ RECREATIONAL HEALTH: Pool/Spa Nurrher of Pools --: Out of Service Pool Natural Bathing Place <br /> _ SITE MITIGATION: Environ Assess UST/CAP _ Loc Iiez Wnste Hez Met PPL <br /> Other Lead Agency Site Agency: RWOCR _ DISC NPL Site R8/H20 0 Other <br /> SOLiD WASTE: Landfill Transfer Sta —_ s Recycling FRC Wnste Storage Fac Ag Wnste/Exempt Site <br /> SW Vehicle No. Onmpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Blyds _ Ker"l <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 ( ) ( ) <br /> DEtIGNATED EMPLOYEE 0 C �� PROGRAM ELEMENT N �S CURRENT STATUS <br /> N OF UNITS EPA iD p: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, the udersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. 1 also certify that I hnve prepared this application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAQUIN CC"TY .Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S Si GNATURE <br /> Title: Rail Program Manager, SJRRCDate: ���/ %7 1 age lot; <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the obove, when applicable, 1, the owner, operator or agent of same, of <br /> the property locatecf at `.`t a?xvq site address hereby authorize the relense of any and all results, geotechnical date and/or <br /> environmental/site stsestment 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 Dnte of Pnyment Payrwit Type Receipt N Check N Recvd By <br /> SUPV <br /> – /– ' -- ACC (0 / / `— UNIT CLK --/--/ <br />