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I <br /> GENERAL PROGRAM FiLE New Change Edit (PROG3) revised 5/21/43 <br /> FACILITYIDN FACILITY NAME <br /> RECORD iD * PRIOR SVEEPS/COMP N <br /> DAIRY: Grada A Grade B Milk Dfnpenser Number of Containers in multi-Head 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 Verdlrg Machines Number of Vending Units <br /> Food Vehicle Hake Llcense N Registretiomi N Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> HOUSING: llctel/Notel No. of Units Jnil/Exempt Institution Housing Abatement <br /> Employee Housing No. of Emplcyeen Approx Dates of OCcuparn-y �/ / to ---J. -- J <br /> LIQUID WASTE: Pumper Vehicle Puaper Yard Ch pmicat Tolleta No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing La Generator Sm Generator <br /> Storage (2-10) Storage (11-50) _ storage ( >50 ) Tronsfer Sta _ Ltd Hauler Yet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools out of Service Pool Natural Bathing Piece <br /> X SITE MITIGATION: Environ Assess X UST/CAP Loc Ha; Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RUQCR DISC NPL Site ROP120 C other <br /> _ SOLID WASTE: Landflil Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehlele No. Ommpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Blydn Kennel <br /> EMERGENCY NOTIFICATION for-this FACILITY andlor PROGRAM DAY/ �} NIGHT <br /> CONTACT 1's ?'ob wa ff h ( 0156g q - 0 <br /> CONTACT 2 <br /> OEN GNATED EMPLOYEE N PROGRAM ELEMENT N CURRENT STATUS <br /> N OF UNITS': EPA ID N: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of Sams, aeknowtedge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity wilt be billed to the party identified es the <br /> BILLING PARTY on this fcrm. I *iso certify that 1 hnve prepared this application and that the work to be performed wilt be done <br /> In accordance with all applicable SAN JOAOUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> I'age 1013 <br /> Title: project -Mane er, Kenned /Jenks Date: 13 October 1995 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the prcperty•tocatcd at t`e abcve site address hereby authorize the release of any and all results, geotechnical date and/or <br /> environnentst/rite assessment fnfcrmation to SAN JOAQUIN COUNiY PUBLIC HEALTH-SERVICES ENVIRONMENTAL HEALTH DIVISICN as soon as <br /> It is avellebte and at the same time it is provided to me or my representative. <br /> Fee A:ncunt Amoint Paid Dote of Payment Payment Type Receipt N Check N Recvd By <br /> RENS �/ / SUPV / / ACCP <br />