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Add Lel ve k c r- s-fes W Gt/4sYrr �e r�o GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/18/ 4 FACILITY ID # () e-f�)-e -FACILITY NAME �� /.c�A�v� ��rd✓�{., � STS (-S • RECORD IO # Pte, CT O p/ PRIOR SWEEPS/COMP # DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Iea Ptant Seating Capacity Sq Ft Market w/Food Prep: Y / N Number of Vending-Machines Food Vehicle Make License # Registration # Color HAZARDOUS WASTE: Tons Generated/Yr __ TIERED PERMIT Facility : CA CE PSR _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Employee Housing No, of Employees ___ Approx Dates of Occupancy ,_J—_j to LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing L9 gyrator Sm Generator Storage (2-10) _• Storage (11-50) Storage C >50 ) _ Transfer Ste Ltd Hauler _ Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place _ SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Hoz Mat PPL /Other Lead Agency Site Agency: RWOCB OTSC NPL Site RB/H20 Q Other SOLID WASTE: Landfill _,Transfer Sta Recycling Fac Waste Storage Fac AS Waste/Exempt Site SW Vehicle � No- ter No. Stationary Compactor Site Ff AvE A 7-7-*[- Sa VECTOR CONTROL: Pou try Farm Max EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 : ( ) C ) CONTACT 2 : DESIGNATED EMPLOYEE # 7 PROGRAM ELEMENT # _ CURRENT STATUS j1��.f ,V-e,. N OF UNITS 19 We,/-ZtrEPA IO #: INSPECTION CODE BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site andlor project specific PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmentat/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Fee Amount Amount Paid Date of Payment Paye. t Type Receipt S Check # Recvd By Co 297I7 RENS C f� 'mom 'r J SUPV I ,/_J ACCT , ,_/ f_... UNIT CLX