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FILE New Change Edit <br /> (PROG3) revised 5/21/93 <br /> riY ID / FACILITY NAME <br /> RECORD ID 0 <br /> PRiOR SWEEPS/COMP AI <br /> _ DAIRYs Grads A Crede B Milk Dispenser pen Number of Containers in Multi-Hood Unit <br /> FOOD: Restaurant Market Commissary Mobile Food <br /> Seating Capacity Produce Stand lee Plant <br /> Sq Ft Market w/Food Prep! Y / N <br /> Temporary Food Facility Special Food Event Vending Machines <br /> Food Vehicle Make Number of Vending Units <br /> Llcente K Registratteri M <br /> Color <br /> _ HAZARDOUS WASTE: Tons Generated/Yr <br /> TiERED PERMIT Facility ; CA CE PBR <br /> _, HOUSING: Hotel/Motel No. of Units Jail/Ex <br /> Employee Housing No, of Employee, <br /> eO Institution Housing Abatement <br /> mp oyees A�+rox Datess of Occupancy <br /> / / to <br /> LiQUID WASTE: Pumper Vehicle Ptxrmr Yard Chemical Toilets <br /> No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursin <br /> Storage (2-10) Storage (11-50) Storage ( >50 g LU Generator Sm Generator <br /> > Transfer Ste _ Ltd Hauler Vet Clinic _ <br /> RECREATIONAL HEALTH: pool/Spa HuTber of roots Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess / UST/CAP Loc Naz Neste <br /> Other Lead Agency Site Agency., Hez Met PPL <br /> A <br /> g y., RWOCB DISC NPL Site RB/H20 Q Other <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fee <br /> SW Vehicle g Ag Waste/Exempt Site <br /> No. Dumpater No. Station Compactor ompactor Slte <br /> VECTOR CONTROL: Poultry farm Max Number of Birds <br /> Kennel . <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM <br /> -� DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE 0 PROGRAM ELEMENT 0 <br /> CURRENT STATUS <br /> S OF UNITS : _ EPA iD 0- INSPECTION CINE <br />'BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of scent, acknowledge that ell site and/or <br /> project specific DNS/EMD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> i[LLING PARTY an this fora. I also certify that I have prepared this application and that the work to be perforwkd wilt be done <br />'in accordance with sit OpPlfc1ple SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or federal laws. <br /> sPPLICANTmS SIGNATURE e� <br /> tile: ro J �INFOR <br /> Date: -a�-`S � Page loll <br /> NITHORIZATI TO RELEASE TiON: in addition to the above, when applicable, 1, the owner, operator or agent of some, of <br />'he property'(ocated at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> nvirornrcntal/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> K is available and at the sssra time It is provided to me or my representative. <br /> Fee Am"t Amount Paid Date of Pa <br /> yment Payment Type Receipt N Check 0 Recvd By <br /> mENS SUPV <br /> — _/__/_ ACCT _/ / UNIT CLK _/ 771 <br />