Laserfiche WebLink
` •GENERAL PROGRAM FILE : New *-- Change Edit (PROG3) revised 5/21/43 <br /> FACILITY [D # ter' �7 p FACILITY NAME FI r_ <br /> RECORD ID PRIOR SWEEPS/COMP #7 <br /> DAIRY: Grade A (�Grade B Milk Dispenser Number of Containers in Mutti-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice 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 # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr lL'.� 4 TIERED PERMIT Facility : CA CE PBR <br /> HOUSING: Hotel/Motel No. of Units ,fait/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy / to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing L9 Generator Sm Generator <br /> Storage (2-10) Storage (11-50) _ Storage ( X50 ) _ Transfer Sta Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Nor of Pools out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RR/H20 Q Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Duster No. Stationary Compactor Site <br /> i <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 ( } ) <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # 7-7 CURRENT STATUS <br /> # OF UNITS EPA ID #: (�P t Al 2 INSPECTION CME <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title- Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of army and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt it Check it Recvd By <br /> REHS / / SUPV _/�/ ACCT UNIT CLK /,/ <br />