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GENERAL PROGRAM FILE New Change Edit _ (PROG.T) revised 5/21/93 <br /> Naw <br /> FACILITY ID xo U Ll 5/ (9 FACILITY NAME I:�o V-(,7a- �0'W rCie IFXG2 �aCi <br /> RECORD ID N M y if O p o2® EE <br /> PRIOR SWPS/cGMP N y y <br /> DAIRY: Grade A Crede B Milk Dispenser NudDer of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market _„_, Commissary Mobile Food Produce Stand tce Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License B Registration ! Color <br /> HAZAROCUS WASTE: Tons Generated/Yr ' TIERED PERMIT Facility : CA CE POR <br /> _ HOUSING: Notel/Motal No. of Units Jail/Exempt institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Oceupency _J__/ to <br /> LIQUID WASTE: Pumper vehicle Purper Yard Chemical Toilets No. Pecks" Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Gor►erstor So Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) _ Transfer Ste _ Ltd Mauler _ Vat Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc HaL Waste Hai Mat PPL <br /> Other Lead Agency Site Ag ---"R1i968 DTSC NPL, Site RB/1120 0 Other <br /> _ SOLID WASTE: Landfilt Transfer Sts ting Fac Waste Storage Fac Ag Waate/Exeapt Sita <br /> SW Vehicle o. Duapster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Fara Max Number of Birds rennet <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 ( ) ( ) <br /> CONTACT 2 ( ) ( ) <br /> DESIGNATED EMPLOYEE N PROGRAM ELEMENT / CURRENT STATUS <br /> S OF UNITS EPA 10 B: INSPECTIOX CODE <br /> BILLING and COMPLIANCE ACIUMEDGEMENT: t, the undersigned owner, operator or agent of Sane, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the <br /> BILLING PARTY on this form. t also certify that I have prepared this application and that the work to be performed will be dorw <br /> in accordance with all applicabl& SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Titte: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of some, of <br /> the property located at the above site address hereby authorf=e the rales** of any and sit results, geotechnical data and/or <br /> environmental/sit& assest information to SAN JOAcUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> smen <br /> it is available and at the same time it is provided to ma or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt f Check S Racvd BY <br /> RENS _J�f SUPV ACCT i U11I71'CLIC <br />