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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 8/?6i01 FACILITY ID # D� ! L/ 7 C FACILITY NAME PFCORD ID # (1� �// PRIOR SWEEPS/COMP a DAIRY: Grade A Grade B Milk Dispenser _ Number of Containers in Multi -Head Unit roon: 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 dense # Registration # Color J� NA7ARDOUS WASTE: Tons Generat/Yr {yf TIERED PERMIT Facility s 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 Sta Ltd Hauler Vet Clinic _ PrCREATIONAL HEALTH: Pool/Spa Number of Pools out of Service Pool Natural Bathing Place _ SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Mat PPL Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 C Other DESIGNATED EMPLOYEE # �( PROGRAM ELEMENT # r CURRENT STATUS ^� # OF UNITS ` EPA ID #: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EIID hourly charges associated with this facility or activity will be billed to the party identified as thA BILLING PARTY on this form. 1 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 r Title: Date. AUTIIORTZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data arid/or envirortimental/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. rce Amount Amount Paid Date of Payment Payment Type Receipt * Check * Recvd By f SUPV __/__/ ACCT ( 1 /f C/ /7 UNIT CLK _/ j WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dumpster No. Stationary Compactor Site VFCTOR CONTROL: Poultry Farm Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM NIGHT DAY�/ CONTACT 1 : /,�e.- ] CONTACT 2 : Of DESIGNATED EMPLOYEE # �( PROGRAM ELEMENT # r CURRENT STATUS ^� # OF UNITS ` EPA ID #: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EIID hourly charges associated with this facility or activity will be billed to the party identified as thA BILLING PARTY on this form. 1 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 r Title: Date. AUTIIORTZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data arid/or envirortimental/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. rce Amount Amount Paid Date of Payment Payment Type Receipt * Check * Recvd By f SUPV __/__/ ACCT ( 1 /f C/ /7 UNIT CLK _/ j