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GENERAL PROGRAM FILE : New v a 'Edit ( ) revised 5/21/93 FACILITY ID # L FACILITY RECORD 10 # / PRIOR SWEEPS 9 DAIRY. Grade A Grade B Ni Lk Dispenser Number of Containers in MuLti-Sead Unit _ GOOD: Restaurant Market Nobita Food Produce Stand Ice Ptant Seating ity Sq Ft Market Prep: Y / N Temporary Food Facility Special Food Event Vending Machines Number of Vending hits Food Vehicle License # Registration # War HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facitity : CA CE POR ' HOUSING: Hotet/Matet No of Units Jait InstitutionHousing Abatement Emptayee Mousing No. of Emptayees Approx Dates of Occupancyl ,/ to LIQUID W►STEz Pumper Vehicter Pumper Yard Chemieat-ToitetsNo. P Tx Ptant MEDICAL WASTE: Primary Carer Acute` Ski tied Nursing Lq Goner~ Sn Generator Storage (2-10) Storage (11-50) Storage C >50 ) Transfer Ste At—d Hauter Yet Ctinic RECREATIONAL HEALTH:. Poot/Spa Number of Poets Out of Service Pact NNaaural Bathing Ptace SITE MITIGATION Environ UST/CAPLoc Haz to Naz Mat PPL �._ Other Lead Agency Site Agency: RWQCB DTSC NPL site RO a Other _ SOLID WASTE: Landfitt Transfer Ste Recycling Fac Waste Storage F Ag Waste/Exempt Site SW Vehfcte No. Dumpster No. statiamiry Compactor Site �.VECTOR CONTROL: Poultry Farm Max Number of Birds t EMERGENCY NOTIFICATION for this FACILITY DAY NIGHT CONTACT 1 C ) C ) CONTACT 2 : C ). Y DESIGNATED EMPLOYEE # �GV # `i�-3 CLOMW STATUS # OF UNITS`: EPA ID #t INSPECTION CODE BILLING and COMPLIANCE a I,, the undersigned owner, for or agent of saw, acknowtedge that alt site sm:Vor project specific PHS/EiD hourly charges associated with this faciLfty or activity wilt be bitted to the identified as the BILLING PARTY an this form.. I atso certify that 1 have prepared this appLication and that"the-work to be performed witt be done in accordance:with atL appticabte SAN JOAQUIN COUNTY ordinance or Stardards and State and/or Federat Laws- APPLICANT'S SIGNATURE aws-APPLICANT'S-SIGNATURE Titte: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above:, when appticabte, I,. the owner, operator or agernt of same,, of the property Located at the above site addrem hereby anhorize the ratemse of any and sit resutts geotechnical data andfor envirorawntat site assessment informatim-to SAN JOA43UTH IC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSItNC as,soon as it is avaitabte and at the same ties it is provided to me or my representative- Fee epr tive.Fee Amount Amount Paid Date of Payment Type Receipt Check # Reew By RENS _,,_/...,--/ ... ....... ACCT l tDCIT CLK �. .N..._...✓