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GEN ORAL PROGRAM FILE New _ Change Edit �1 (PROG3) revised 5/21/93 FACILITY ID # FACI L[TY NAME I�` n I ,e RECORD ID # PRIOR SWEEPS/CCMP l� DAIRY: Grade A Grade B Milk Dispenser _ Number of Containers in Multi-Head Unit _ FOOD: Restaurant _ Market _ Commissary _ Mobile Food _ Produce Stand _ Ice Plant Seating Capacity Sq Ft Market w/Food Prep: Y / N Temporary Food Facility _ Special Food Event _ Vending Machines _ Number of Vending Units Food Vehicle Make ,License # Registration # Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ PBR _ HOUSING: Hotel/Motel No, of Units Jail/Exempt Institution Housing Abatement Employee Housing _ No. of Employees Approx Dates of Occupancy 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 Hai Waste Hai Mat PPL _ Other Lead Agency Site _ Agency: RWQCB DTSC _ NPL Site _ RB/H2O Q _ Other SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac _ Ag Waste/Exempt Site SW Vehicle No. Dumpster _ No. Stationary Compactor Site I VECTOR CONTROL: Poultry Farm _ Max Number of Birds KenneI EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 : CONTACT 2 : DESIGNATED EMPLOYEE It PROGRAM ELEMENT # .z •� •7 "� CURRENT STATUS # OF UNITS : EPA ID #: "l_aO Z !1)`` INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, acknowledge that all site and/or prof ect specific PHS/EHD 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 applicable SAN JOAQUIN COUNTY 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, I, the owner, operator or agent of some, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmentaL/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 Payment Type Receipt # Check # Recvd By RENS _/ /_ SUPV _/_/_ ACCT _/ /_ UNIT CLK _/_/_