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RAM FILE New Change Edit (PROG3) revised 5/21/93 CITY iD 0 VICE?e q Z) FACILITY NAME RECORD ID — l 5�� PRIOR SWEEPS/COMP R DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit FOOD: Restaurant Market Commissary __ Mobile food Prockice Stand Ice Plnnt Seating Capacity Sq Ft Mnrket w/Food Prep: Y / N Temporary Food Facility Special Food Event Vending Machines Number of Vending Uri its Food Vehicle Make License N RegIstratiai 0 Color HAZARDOUS HASTE: Tons Generated/Yr _ TIERED PERMIT Facility : CA CE PBR HOUSING: Notel/Motel No. of Units Jmit/Exenpt institution Housing Abatement Employee Housing No. of Employees Approx Dates of Occupancy _/—/— to —�—J LIQUID WASTE: Purger Vehicle Purrper Yard Chomical Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Cire Skilled Nursing Lg Generator Sm Generator Storage (2-10) _ Storage (11-50) Storage ( >50 ) __ Transfer Sta _ ltd Hauler Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa Nvrber of Pools Out of Service Pool Natural Bathing Piece XX SiTE MITIGATION: Environ Assess XX UST/CAP Loc Iiaz Wnste Haz Mat PPL Other Lead Agency Site Agency: RWOCR DTSC NPL Site RB/H20 0 Other _ SOLiD WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dumpster No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1*: Mr. James McCarty (202) X68- 4682 ( ) CONTACT 2 : Mr. Amerik Singh (202) 333- 1038 t ) DE§IGNATED EMPLOYEE It D( / PROGRAM ELEMENT A � / CURRENT STATUS M OF UNITS : EPA ID 9: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, 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 as the BILLING PARTY on this form. I also certify that 1 have prepared this application and that the work to be performed will be dome In accordance with all applicable SHIN JOAOUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANTS SIGNATURE 1U Page 1011 Title: 4-5; Date: S AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of the property tac2tod at 0,e above site address hereby authorize the release of any and all results, geotechnical data end/or envirormental/site essessment 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 Arrount Paid Date of Payment Payment Type Receipt 0 Check 0 Recvd By c8 1012Y ll RENS _/ / SUPV — /_ _/_ _ ACCT /�S /_Z UNIT CLK _/ /