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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID 0 FACILITY NAME <br /> RECORD ID X PRIOR SWEEPS/COMP R <br /> _ DAiRY: Grade A Grade 8 Milk Dispenser ___ Number of Containers in Multi-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 Mnchines Nirtber of Vending Units <br /> Food Vehicle Make License N _ Registratioai M Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PFRMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of Units Jail/Exempt institution Housing Abatement <br /> Employee Housing No. of Employees _ _ Approx Oates of Occupancy _/ / to <br /> _ LIQUID WASTES Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) Storage (11-50) Storage ( >50 ) Transfer Sto _ Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Nunher of roots --- Out of Service Pool Natural Bathing Place <br /> uT SITE MITIGATION: Environ Assess X UST/CAr Loc Haz Waste Hez Mat PPL <br /> Other Lead Agency Site Agency: RWOCR _ DTSC NPL Site R8/H20 Q Other <br /> SOLiD WASTE: Landfill Transfer Ste — 0 Recycling me Waste Storage Fac Ag Wsste/Exempt Site <br /> SW Vehicle No. Drmpster __ No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAM DAY NIGHT <br /> CONTACT 1't ( ) ( ) <br /> CONTACT 2 : ( ) ( ) <br /> DESIGNATED EMPLOYEE M PROGRAM ELEMENT 0 CURRENT STATUS <br /> N OF UNITS : EPA iD 9: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned caner, operator or agent of 9-mru, acknowledge that atl site end/or <br /> project specific PMS/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 hove prepared this application and that the work to be performed will be done <br /> In accordance with ell applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State end/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Rail Program Manager, SJRRC Date: Page 1011 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at t-e abcve site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormentel/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 k Check K Recvd By <br /> E <br /> _/ / SUPV _ / / _ ACCP ^/ _/ UNIT CLK _/ / <br />