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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 FACILITY 10 At 7 FACILITY NAME /^� v/f ii i %�`-0 P� RECORD ID a V ' 3 PRIOR MEPS/CCKP 0 ,e0 cc.-)oo S 2 O DAIRY: Grade A Grade 3 milk Dispenser Ntnber of Containers in Multi-Read Unit _ FOOD, Restaurant market Commissary mobile Food Produce Stand Ice Plant Seating Capacity Sq Ft market w/Food Prep: Y / N Teaporary Food Facility Special Food Event Verding Machines Nunber of Vending Units Food Vehicle make License t Registration 0 Color HAZARO(x1S WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR _ HGUSING: Hotel/Motel No, of Units Jail/Exempt Institution Housing Abotement Eaplayee Housing No. of Employees Approx Oates of OccuPencY _J_� to LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lq Generator Sm Generator Storage (2-10) _ Storage (11-50) Storage ( >50 ) _ Transfer Ste Ltd Hauler Vet Clinic RECREATIONAL HEALTH: Pool/Spa Humber of POOLS Out of Service Pool Natural Bathing Ptace SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Hai Mat PPL Other Lead Agency Site Agency: RIACB DTSC NPL Site RB/H2O 0 Other _ SOLID WASTE: Landfill Transfer Sts Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SU Vehicle No. Ourpater No. Stationery Coapsctor Sit• VECTOR CONTROL: Poultry Fara Max Number of aIrds KerneL EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 CONTACT 2 ( ) ( ) DESIGNATED EMPLOYEE ! PROCR/1M E I! 1 ;2 `J SS CURRENT STATUS ! OF UNITS EPA ID it: INSPECTICU CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, acknowledge that all site and/or project specific PNS/EHO hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this fors. I also certify that I have prepared this application and that the' work to be performed will be done in accordance with all applicaW a SAN JOAoUIM COUNTY Ordinwxce Codes and/or Standards Ord State and/or Federal lairs. APPLICANT'S SIGNATURE Title! Oats- AUTHORIZATION TO RELEASE INFORl1ATION: In addition to the' above, when applicable, I, the owner, operator or agent of sae», of the property located at the above site address hereby authorize the release of arty and all results, geotachnical data arxVor erivir«mental/site assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES E)IVIROWXTAL HEALTH DIVISION as soon ai it is available and at the same ties it la provided to me or my representative. Fee Aaiant Amount ! Check ! Recvd By P id Date of Payment Payment Type P s^ $ '7 Cc REHS _J—J — -� _I_—__J ACCT UNIT CLX