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GENERAL PROGRAM FiLE New <br /> Charmge Edi t <br /> "� �---�– (PROG3) revised 5121/43 <br /> FACILITY 10 R %> <br /> FACILITY NAME � <br /> RECORD to 0 <br /> �- x ! _: ✓ PRIOR SWEPS/CdiP N <br /> DAIRY: Grade A Grade B <br /> Milk Dis mser <br /> P�* Number of Containers in Multi-Need Unit <br /> FOOD: Restaurant Market Comrml3sam <br /> Y _—_ Mobile Food Produce Stand <br /> Seating Capacity Ice Plant <br /> Sq Ft _ Market u/Food Prep! Y / N <br /> Temporary Food Facility Special Food Event Vending Maclmines Number of Vending Units <br /> Food Vehicle Make License N -- <br /> Registretfai mY Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA � pBR <br /> �. HOUSING: Hotel/Notal No. of Units Jai(/Ex t Institution <br /> � Housing Abatement <br /> Emmpioyee Housing No, of Employees _ Approx Dates of Occupancy / / to <br /> — LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. <br /> Package Tx Plant <br /> •____ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) Storage Transfer Ste , Ltd Hauler Vet Clinic <br /> PAMr <br /> RECREATIONAL HEALTH: Poot/Spa Number of Pools Out of Service Pool lurraf61�kf1�i{n`�Fj Place <br /> x SITE MiTiGATION: Environ Assess x USf/CAP Loc Ilez haste Hax Met PPL DEC 2 81995 <br /> other Lead Agency Site Agency: RVOCR ofse NPI Site R8/H2o G:.;ie ..,Other <br /> SOLID WASTE: Landfill Transfer Ste Recyciinq Fac Llnste Storage Fac A'V'WMt6A eirf7t, te,,. <br /> SW Yehicl♦ Na. Oumr(+eter No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EM£RGENCT NOTIFiCAT10N for this FACILITY andlor PROGRAM DAY NIGHT w <br /> Mr. Kevin Kenworthy <br /> CONTACT 1�� (209 ) 951 .2169 � 209) 95 1-2.188 <br /> CONTACT 2 : Ms. Terri Pun et - a trey { 538S2�F l4175-- —ZCrT 3457 — <br /> DEtIGNATED EMPLOYEE # ,,"�- PROGRAM ELEMENT S �u.� �_ � CURRENT STATUS <br /> 9 OF UNITS — EPA 10 It 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/END hourly charges associated with this facilfty or activity kilt be billed to the party identified as the <br /> BILLING PARTY on this forme. I also certify that I have prepared this application and that the work to be performed will be done <br /> In accordance with all applicable SAN JOA4UfN COUNTY Ordi=odardards mrd State ardlor Federal lamas. <br /> APPLICANT'S SIGNATURE <br /> Title- Date, Page 1f111 <br /> /l_��_ �y� <br /> AUTHORIZATION TO RELE FORNArION: In addition to the above, when applicable, f, the owner, operator or agent of same, of <br /> the property :ocited at t o abcvi site address hereby authorize the release of any and all results, geotechnical data end/or <br /> envirormmentot/zica assestmment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the some time it is provided to me or my representative, <br /> Fee Amount Anrxnt Paid Date of Payment Payment Type Receipt A check 0 Recvd By <br /> -- <br /> - �� UHI T CLQ �..../ l <br />