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M FILE New Change Edit (PRO0 revised S/21M some A& fFACELtTY7IO E FACILITY NAME PRIOR SWEEPS/CHIP f DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Ned Unit FOOD: Restaurant Market commissary Mobile Food Produce Stand Ice Plant Seating Capacity Sq Ft Market Wood Prep: Y / N Temporary Food Facility Special Food Event Vending Machina Nud:er of Vending Units Food Vehicle Make License B Registration S Color HAZARDOUS WASTE: Tons Genersted/Tr ' TIERED PERMIT Facility : CA CE Pez _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement Employee Housing No. of Employees Approx Dates of OeecPww.Y __J_J to LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2-10) _ Storage (11-50) __ Storage ( >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 Hae Mat PPL Other led Agency Site Agency: MACE DTSC NPL Site Re/H2O 4 Other 110 WASTE: Landfill Transfer Sts Recyct Ing Fee W e ge StoraFee Ag Wasta/Exaspt Site SW Vehicle No. _ Duipster No. - Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Birds _^__ Kemal F EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT I CONTACT 1 $` 0�6 0 C ) CONTACT 2 f ) ( ) DESIGNATED EMPLOYEE 063 If PROGRAM ELEMENT 0 CURRENT STAtUS S OF UNITS Z-2 _ EPA ID N: INSPECTION CODE BILLING and COMPLIANCE ACKW&EDGEMENT: t, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PRS/EW hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY an this fora. I also certify that t have prepared this application and that the work to be performed wilt be done in accordance with all applicable SAN JOAGUIN COIAM Ordinance Codes and/or Standards and State and/or Federal Laws- APPLICANT'S SIGNATURE Title: Date., AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, t„ 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 envirorawxual/site assessment information to SAN JOAQIIIN COUNTY PUBLIC HEALTN SERVICES ENVIRONMENTAL HEALTN DIVISION, as soon as it is available and at the same time it is provided to am or my representative- Fee Amount Amount Paid Date of Payment Payment Type Receipt S• Check 0 Recvd By REHS ACCr UNIT CIX _,.f_... .r