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GE4IERAL PROGRAM FILE : New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY 10 R FACILITY NAME <br /> RECORD ID g PRIOR SWEEPS/COMP A <br /> DAIRY: tirade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand lee Plant <br /> Seating Capacity Sq Ft Market w/rood Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Mnchlnes Number of Vending Units <br /> Food Vehicle Make License N Registratiai 0 Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility - CA C£ POR <br /> _ HOUSING: Nate!/Motel No. of units J91(/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of occupancy _/ / to <br /> LIQUID WASTE: Pumper Vehicle Punier Yard C.11mlent Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( X50 ) Transfer Sta r Ltd Heiner Vet Clinic <br /> RECREATIONAL HEALTH: PootApa Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ AssessUST/CAP Loc lint Waste Hat Mat PPL <br /> Other L Agency 777 Lead A Site A ency: RWOCR DISC HPL Site 98/1120 0 Other <br /> Y <br /> SOLIO WASTE: Landfill Transfer Ste Recycling Fac Wacte Storage Fac Ag Waste/Exempt Site <br /> T SW Vehicle No. Du -etter No. Stationary compactor Site <br /> VECTOR CONTROL: Poultry Farm Max NurbPr of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITi' and/or PROGRAM DAY NiGHT <br /> L <br /> TACT 1't Rob Wooton - Stockton Savings Bank (209 ) 948 - F870 t ) <br /> rACT 2 e Mike Holbrook-Clayton Environmental _ 1510 ) 426 - 0106 ( ) <br /> DESIGNATED EMPLOYEE ! CooI L I <br /> PROGRAM ELEMENT CURRENT STATUS <br /> 0 OF UNITS EPA ID 0: INSPECTION CODE t _ <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I oleo tify that i have prepared this application and that the worn to be performed will be done <br /> in accordance with all a cable 5AN J OUI Ol1NTY Hance Codes end/or Standards end State and/or Federal laws. <br /> APPLICANTS SIGNATURE l �tob Wooton <br /> 1'crkc Il)Il <br /> Title- Vice President - Stockton Savings Bank Date: Dec. 23, 1993 <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnfcat date and/or <br /> environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> �i it is available and at the same time It Is provided to me or my representative. <br /> mount Amount Paid U Date of Payment Payment Type Receipt N Check 0 Recvd By <br /> 0 <br /> RENS �/ / SUPV �' _/- /—�— ACCT / /—J UNIT CLK ^/ / <br />