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A-23-1997 2:43PM FROM- P. d <br /> jtOGRAN FiLE New CtuW,ge Edit (PROc3) revised 5/21/93 <br /> ►Ty ID / <br /> FACILITY ff;;], <br /> F <br /> ca" ID S PRIOR SWFErS/COMP s <br /> AIRY: Grade A Grade B Milk Diapenser Number of Containers in Multi-Mead Unit <br /> FOOD: Restaurant Market Can+efaaary Moblle road PrvAme stand fee Plant <br /> Seating Capselty Sq Ft Market w/food rr p: T / N <br /> 1-1w ery Food Facility Special rood Event Vendiry Machines Number of Vending Unfts <br /> Food Vehicle Make License S Reg4tretiai 0 Color <br /> HAZARDOUS WASTE, Torts Generated/Yr TiERED PERMIT racttity : CA CE POR <br /> HOUSING: hotel/Motel No. of Units Jolt/Exempt institution Housing Abatement <br /> Employee Housing No. or Employees At.Vwox Dates of Occupwxy / / to <br /> LIQUID WASTES Pumper Vehicle Purmr Yard Clr«mical Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Priaery Care Acute Core Skllted Nursing L(i Generator Sm Generator <br /> Storage (2-10) — Storage (11-SO) — StoroAe ( >50 ) Tronefer $to Ltd Hauler Vet Ctinie <br /> RECREATIONAL NEALTR: Pool/Spa Nurher of Poets Out of Service Pool Natural ttathsty Place <br /> STTE MITIGATiON! Enviran Assees -.S(—/ UST/CAP Loc hat Waste Hai Met PPL <br /> other Lead Agency Site Agency! RUOCR OTSC NPL Site RB/M Q Other <br /> h <br /> SOLID WAST£t Landfill Transfer Stn Recycling Tne Waite Storage Fac Ag Woste/Exempt Site <br /> SW Vehicle No. Drsrpster No. Stationary Compector Site <br /> r, VECTOR CONTROL: Poultry Farm Mex Nosrfr_r of Birds Kennel <br /> EMERGENCT NOTIFICATION for this FACl/L//ITY std/or PROGRAM OAT NIGHT <br /> CONTACT 1'e 01j-ein <br /> CONTACT 2 ( ) ( ) <br /> 00IONATED EMPLOTEE N PROGRAM ELEMENT S FaMRENT STATUS <br /> S OF UNITS ! EPA TD S: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT! 1, the undersigned carer, operator or agent of same, acknowledge that Al site and/or <br /> project specific PMS/END hourly charges associated with this facitfty or activity wilt be bftled 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 applicable SAN JOAQUIN COUNTY Ordinance Codes end/or Standards and State end/or Federal taws. <br /> APPLICANT'S S <br /> IGNATURE 1 <br /> Ttcla: J c� �1�1 Date: Pirge 1(111 <br /> AUTHORIZATION TO RELEASE INFORMATI : 1. addition to the above, when applicable, I, the r, operator or egent of %&Te, of <br /> the property'Located at the above site address hereby sutherize the release of any and all results, geotechnicat data and/or <br /> ornvironmental/sits assessment information to SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL WEALTH DIVISION as Soon as <br /> It is aveilable and at the saw time it is provided to roe or W representative. <br /> fee Amorrlt Amount Paid Date of Payment payment Type Receipt If Check S Recvd ay <br /> t . . <br />