Laserfiche WebLink
GENERAL PROGRAM FILL : New change Edit (P00) revised 5/21/93 <br /> i <br /> � I <br /> FACILITY ID 0 FACILITY <br /> RECORD ID 0 PRIOR SWEEPS/Comp a � <br /> i <br /> DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Out itl-Head Unit <br /> _ FOOD: Restaurant Market Commissary Mobile Food Produce Stard Ice Plant <br /> Senting Capacity Sq Ft Market w/Food Prep: Y V N <br /> Temporary Food Facility Speelal Food Event Vending Machines Ntnber of Vending Units <br /> Food Vehicle Make License # Registration 9 Color <br /> ns <br /> HAZARDQUS WASTE! Tans Generated/Yr; <br /> TIERED PERMIT fecltlty ! C/1 r -CE PBR <br /> HOUSING: Hotel/Motel No, of Units Jail/ExenRt Institution ! Noupirg Alaatemer�t <br /> - Eaptoyee Housing No. of Employers Approx Dates of Occupancy�'/ J I� to <br /> LIQUID WASTE! Pumper vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> NED[CAL WASTE: Primary CareRoute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _' storage (11-5Q) Storage ( >50 ) Transfer Sta _' Ltd M"Ier Vet Clinic <br /> ECREATIONAL HEALTH: Pool/Spa 'Number of Pools out of Service Pool Natural Bathing Place <br /> / <br /> SITE MITIGATION! Environ Assess e" UST/CAP Loc Haz Waste Max Mat PPL <br /> Other Lead Agency site Agengy: RWDC$ DTSC HPL Site RB/HZ(1 O O[her <br /> _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste storage Fac A6 Waste/Exempt Site <br /> SW vehicle No. bumpster No. Stationer Coapoctor Site <br /> Kennel ' <br /> VECTOR CONTROL! Poultry Farm i Number of Birds - <br /> i <br /> EMERGENCY NOTIFICATION for this FACILITY arc!/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 e <br /> DESIGNATED EMPLOYEE it �� `� ` PROGRAM ELEMENT !! CURRENT STATUS <br /> >Y OF UNITS : EPA ID *4 INSPECTION CODE - 2,Z1 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknoledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to he 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 he done <br /> in accordance with ell applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and or federal laws_ <br /> APPLICANT'S SIGNATURE <br /> Title.- , f i Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: `Jn,additich to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all tewlts, I9totexf nice' date and/or <br /> gtvirornmental/site assessment information to:SAN JWIoUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTA HLALTN DIVISION as soon as <br /> it is available and at the same time it I$ provided to me or my representative. <br /> Fee Amwnt Amount Paid Date of Payment Payment Type Receipt # Check a Recvd By <br /> I <br /> Zi <br /> i <br /> —/—� ACCT <br /> RE _/� I UNIT SLK _ ../-T <br /> HS ��_� __. <br /> E0'd Zb80LZZSTbT 01 WOdd WdS0:E0 S66T-2,0—b0 <br />