BILLING - Laserfiche WebLink

Home Browse Search

GENERAL PROGRAM FILE New _ _ Change Edit (PROG3) revised 8/26/03 FACiLi1Y 10 N (V1315� FACILITY NAME / 00 1 V l RECORD 10 0161 ', I 3 PRIOR SWEEPS/COMP M _ DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Multi-Head Unit n ; —LIFOOO: Restaurant I/ Market Commissary Mobile Food Produce Stand Ice Plant Seating Capacity�)l- Sq Ft I? -� Market w/Food Prep: Y / N Tarhorary Food Facility Special Food Event _ Vending Machines Number of V"Ine units Food Vehicle Make License s Registration R 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 _J / to LiQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Ste Generator Storage (2-10) _ Storage (11-70) _ Storage ( >50 ) _ Transfer Stm 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 Hez Waste Haz Mat PPL Other Lead Agency Site Agency: RWOC8 DiSC NPL Site RB/H20 0 Other _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dumpster No. Stationary Compactor Site _ VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel — EMFPGEm1CY NOTIFICATION for this FACILITY and/or PROGRAM rr DAY NiGHT C011TACT 1 : CONTACT 2 DESIGNATED EMPLOYEE Nh PROGRAM ELEMENT 11 (V CURRENT STAAlJ TUS 0 OF UMTS : EPA ID 0: INSPECTION CODE :-. BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that sit site and/or prof-act Specific PNS/EHD hourly charges associated with this facility or activity will be bitted 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 app icable SAN JOAQUiN C"TY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE \\ l� M • Title: )✓\� lA��► Date: AUTHCRiZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, 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 and/or if", environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENViRONMENTAL HEALTH DIVISION as soon as is available and at the same time it is provided to me or my representative. hFee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check / Recvd By 6 RENS Q /tel c SUP _/_f ACCT J UNIT CLK / J/