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GE4E2A11 PROGRAM FILE New Change Edit (PROG3) revised 8/26/93 <br /> :FACILITY ID # � / _ FACILITY NAME <br /> RECORD ID 0 (� �0� Q %� PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Need Unit <br /> _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vendine Unita <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy �_J to <br /> _ LIOUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-90) _ Storage ( »0 ) _ Transfer $to _ Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa \J( Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess ` UST/CAP Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWOC8 DTSC NPL Site RB/H2O 0 Other <br /> _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exeapt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of 81rds Kenvw! <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> ylfl2 <br /> CONTACT 1 : AL,4Aj b ) 4_W, 6o 55 (5/O )tet -6798 <br /> CONTACT 2 . ( ) <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> 7 <br /> # OF UNITS EPA ID #: INSPECTION CODE : 300 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that alt site and/or <br /> project specific PNS/END hourly charges associated with this facility or activity wilt be bitted to the party identified as the <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done <br /> In accordance with all applica to SAN JOAQUIN COUNTY Ordinance Codes arKVor^Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE ` Nl <br /> Titte: ` P )�X, Date: ;"AR-0-4 T' 1c, <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to ihe above, when applicable, I, the ownw:r, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as some as <br /> it is available and at the same time it is provided to me or ay representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS ACCT �a�, UNIT CLK _f__J <br />