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GENERAL PROGRAM FiLE t New Change Edit (PR 003 Periled S/21/03 FACILITY ID / JFACILITY NAI! 2ECM0 ID / PRIOR SWEEPS/ / _ DAiRTt Grode A Crabs IT __ _ Milk Dlaperrser Nurber of Containers In Multi•Naed Unit tow t Reatowent Market Coaralssary , Mobile Food _ Produce Stand Ice Plant Booting Capacity SQ Ft Market w/rood Pre(w: Y / M Temporary Food Facility_ Special rood Event _ Vending Machines Ntrber of Vending Units Food Ysttlels Make License / Registraticri / Color 1 HAZARDWS WASfEi Tons Gerxrsted/Tr TIERED PERMIT Facility : CA CE PIR HOtnIMGI Natal/Motel _ Me. of lktits Jail/Exeopt Institution Rousing Abatement EAployes Housing No, of Erptaytes Ar.prox Dotes of Occupancy _/ /^ to _ LIQUID WASTEi Riper Vehicle ^ P%P"r yard — Che+aleet Tollets No. Package Tx Plant _ MEDICAL WASTE: Prisrory Care ^ Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2.10) _• Storage (11-SO) _ Stornge ( �50 ) _ Transfer Ste _ Ltd Haller Vet Clinic — RECREATIONAL HEALTH: POOL/Spa Hu+fier of roots Out of Service Pool Nature Bathing Place SITE MITIGATION: Environ A cess USF/UP loo Hs2 Waste Haz Mat PPL l Other Lead Agency Eltez Agency: ALACR DiSC `_ NPL Site RB/H2O 0 Other _ SOLID WASTE: L"(I tl Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exerrpt Site SW Vehfele No. Dretrytter No. stations y _ stationary C ospeetor site VECTOR CONTROLt Poultry Fares ilex Humber of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAT NIGHT CONTACT 1"t _ Na r1 CONTACT 2 DE31GNATED EIVLOTEE 1 t�`lJ PROGRAM ELEMENT / /J; /,�nJ_�RRENT STATUS 1 OF UNITS i __ EPA 10 1: L/ v INSPECTION CCOF 9ILLiM0 and COMPLIANCE ACT*M FDGEMENT: 1, the udersfgned owner, operator or agent of two, acknowledge that all site and/or project specific VMS/EMD hourly chargee associated with this facl;ity Or activity will be billed to the party identified as the BILLING PARTY on this form. i also tify that i ve epared this application and that the work to be performed will be done In occordanes with all appl JOZ N TY In-once Codes and/er Standards and State and/or Federal laws, APPLICANT' IGNATLIRE t 10 �CTrtle: X �� 1'nRe 1011 Deter AUTHORIZATION TO RELEASE'INFOINATIDNt In addition tW the above, when applicable, 1, the owner, operator or agent of setae, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envirorsmental/site assesatent Information to SAN JOAOUIN CCUNTt PUBLIC HEALTH SERVICES ENYIRON)IENTAL HEALTH DIVISION as soon as it 1s available and at the same time it is provided to me or my representative. Fee AtaQtett Amount Paid Data of P■yrrnt Paywont Type Receipt 1 Check / Rtcvd /y RE HS _/`/ SUPV _ [ACCT / / UNIT CLC `J /