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1 a <br /> _ New ✓ Cha+oge Edit (PRM3) revised 5/21193 <br /> GENERAL PROGRAM FiLE _ <br /> FACILITY ID FACILITY NAME it <br /> RECORD :D �tI) � -- PRIOR SWEEPS/COMP l _ <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Conte,inera in Hutti-Head Unit <br /> FOOD: Restaurant Market Cammissrry ^_ Mobile Food Produce Stand Ice Plant <br /> Seatinq Capacity Sq Ft Market w/Food Pr � <br /> prep: y / N <br /> Temporary food Facility special Food Event Vendfrxl Mnchii,es Humber of Vending Units <br /> food Vehicle Make License N Regis.tratieri ff Color <br /> :I <br /> i <br /> HAZARDOUS WASTE: Tons Generated/Yr _ TIERED PERMIT Facltity CA CE POR <br /> HOUSING: Hotet/Notel Na, of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing NO. of Employees Approx Dates of Occupancyl1_____/ / to <br /> LIQUID WASTE, pumper Vehicle Puffer Yard Chemical Toilets ito:� Package Tx Plant <br /> i <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-to) T� Storage (11-50) Storage ( >50 ) Transfer Sta _ Ltd Hauler _„^ Vet Clinic <br /> i <br /> _ RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of SkrvicePoot Natural Bathing Place <br /> i <br /> SITE MITIGATION: Environ AssessUsr/CAP Lac HaE Waste Hax! Met PPL <br /> Other Lead Agency Site Agency, RWOCR DiSC NPL Site RB/H20 9 Other <br /> I <br /> SOLID WASTE: Landfill Transfer Ste Recycting Fac waste,Storage Fac Ag Waste/Exempt Site <br /> SW Vehict• No. Durpater No. Stationary Compactor Site <br /> i <br /> VECTOR CONTROL: Poultry ram Max NLWFbAr of Birds Kennel <br /> EMERGENCY NOTIfICATION for this FACILITY and/or PROGRAM DAY NiGHT <br /> CONTACT 1's <br /> CONTACT <br /> 001GHATED EMPLOYEE # PROGRAM ELEMENT N 5� iCURRENT STATUS <br /> NOF UNITS EPA ID S: 1NSPECi1C+N CODE <br /> 315 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or ,agent of game, acknowtedge that Bit site and/or <br /> project specific PHS/f HD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I alae certify that i have prepared this application and that the work to be performed will be done <br /> in accordame with sit applicable SAH JOAQUIN COUNTY Ordinance Codes and/or standards and State and/or Federal laws. <br /> i� <br /> + it <br /> APPLiCANTIS SIGNATURE ; <br /> fags 1011 <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, i, t��he owner, operator or agent of same, of <br /> the property at the above aite address hereby authorize the release af'any ar1R all results, geotechnical data and/or <br /> environmental/site 090tiMtent information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the am* time It is provided to me or my representative. <br /> Fee Amxxmt Amount Paid Date of Payment Payment Type Receit N Check N Recvd By <br /> a � � Do <br /> RENS �! / SUPV / �! ACCT <br /> i <br />