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GENERAL PROGRAM FILE : New _s Change Edit _ (PROG3) revised S/21/93 FACILITY 10 3 FACILITY NAME RECORD 10 0 D a PRiOR SWEEPS/CCIAP IR DAIRY: Grade A Grade B milk Dispenser Nurber of Containers in Multi-Head Unit _ FOOD: Restaurant Market Commissary mobile Food Prod— Stand ice Plant Seating Capacity Sq FtMarkat w/Food Prep: T / N Temporary Food Facility Special Food Event 2//` Vending Machines Nudxr of Yarding Units Food Vehicle make License ! Registration N Calor HAZARDOUS WASTE: Tons Generated/Yr I TIERED PERMIT Facility : CA CE PBR HOUSING: Notel/Motel No. of Units Jail/Exempt Institution Housing Abatement Emplayee Housing No. of Employees Approx Dates of Occupancy J__� to LIOU10 WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant _ MEDICAL WASTE, Primary Care Acute Care Skilled Nursing Lg Gerwrator Sm Generator Storage (2-10) _ Storage (11.50) _ Storage ( >50 ) _ Transfer Ste Ltd Hauler _ Vet Clinic _ RECREATIONAL HEALTH! Poot/Spa Humber of Pools Out of Service Pool Natural Bathing Place _ SITE MiTIGATICN: Environ Assess UST/GAP Loc Naz Waste Haz Hat P9L Other Lead Agency Site Agency: Rwca OTSC NPL Site Ra/1" 0 Other _ SOLID 1,4kSTE: Landfill Transfer Sts Recycling Fac Neste Storage Fac Ag Waste/Exempt Sits SU Vehicle No. Dumpater No. Stationery Campector Site VECTOR CONTROL: Poultry form Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAT NIGHT CONTACT 1 CONTACT 2 ( ) ( ) DESIGNATED E1IPLOYEE x PRO(7LAN ELEMENT 0L � (i�? CURRENT STATUS 1 OF UNITS EPA 10 S: INSPECTIOII CO011 BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of 98010, 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 form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all applicable SAN JOAOUIm COUNTY Ordinance Codes and/or Stand4rds and State and/or 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 sea, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/sitz assessment inforeietion to SAN JOAQUIN COLOTTY PUBLIC HEALTH SERVICES MIROW14UTAL HEALTN DIVISION as soon as it is available and at the same time it it provided to me or my representative. Fee Amount Amount Paid Date of Payment"7771 d nt Type Receipt 0 Check ! Red By RENS �l_� _J�! ACCT Gj / LIMIT CLX