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GENERAL PROGRAM FILE New ChAnge Edit (PROG3) revised 5/21/93 FACILITY iD 0 FACILITY NAME RECORD iD 0 PRIOR SWEEPS/COMP A _ DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Haed Unit FOOD: Restaurant Market Cormissmry __ Mobile rood Produce Stand Ice Plant Seating Capacity Sq Ft _^ Mnrket w/Food Prep: Y / N Temporary Food Facility Special Food Event Vending Mnchlnes Number of Vending Units Food Vehicle Make License N Registration N Color T_ HAZARDOUS WASTE: Tons Generated/Yr TIERED PFRHIT Facility : CA CE PBR _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abaten-nt Employee Housing No, of Employees Approx Dates of Occupancy _/_/_ to _ LIOUiD WASTE: Pumper Vehiclt Pumper Yard Chr-mleal Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2-10) _ Storage (11-50) _ Storoge ( >50 } Transfer Stn Ltd Hauler Vet Clinic _ RECREATIONAL HEALTH: Poo(/Spa Nunher of Pools Out of Service Pool Natural Bathing Place SiTE MITIGATION: Environ Assess 2�—f UST/CAP Loc Hez Waste Haz Mat PPL Other Lead Agency Site Agency: RWOCR DiSC NPL Site RB/H20 D Other _ SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. DtNr"ter No. Stationary Compactor Site VECTOR CONTROL: Poultry farm Max Nurb.r of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1': Ms. Shirley Gregg (909 ) 95 +2377 CONTACT 2 . Ms. Roberta M. Kaitz (510 ) 582--1997 ( ) DOIGNATED EMPLOYEE 0 PROGRAM ELEMENT N 2 SU CURRENT STATUS N Of UNITS : EPA ID N: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, 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 es the BILLING PARTY on this form. I also certify that 1 have prepared this application and that the work to be performed will be done In accordance with all applicableSAN DJOOAAOUIN COUNTY Ordinance Codes andlor Standards and State and/or Federal laws. APPLICANT'S SIGNATURE L ^^ Hygienetics Environmental Services, Inc. Page 10BTitle: ll; E Date: June 11, 1996 AUTHORIZATION TO RELEASE TNFCRMATiON: in addition to the above, when applicable, 1, the owner, operator or agent of some, of the prrfk;ty•lccatac+ a; the abov,, site address hereby authorize the release of any and all results, geotechnical data and/or envirorroentsl/sits asses::aent information to SAN JOAOUIN 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 0 Recvd By Z�;�Cy- 1i3 �T 3 SUPV ,/_—/ ACCP` —�/ /—' UNIT CLK