BILLING - Laserfiche WebLink

Home Browse Search

GENtRAL PROGRAM FILE New Change Edit (PROG3) revised 8/26/93 i FACILITY 10 # /V'1FACILITY NAME l/J`� l nlaJ l i RECORD 10 # I �' I PRIOR SWEEPS/CCMP # — DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit FOGO: Restaurant I/ Market Commissary Mobile Food Produce Stand Ice Plant Seating Capacity D Sa Sq Ft j?UC7 J� Market w/food Prep: Y / N Temporary Food Facility Special Food Event _ Vending Machines Nurber of Vending Unit• Food Vehicle Make License # Registration k 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 f�/ 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 ( 3-90 ) _ Transfer Ste 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 Naz Waste Haz Mat PPt Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 0 Other _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Duirpster No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel EHFPCENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 CONTACT 2 ( — DESIGNATED EMPLOYEE # G� PROGRAM ELEMENT 0 (G ZS CURRENT STATUS 0 OF UNITS EPA ID #: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or projc-ct specific PHS/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 applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Stardards and State and/or Federal laws. r � 1 APPLICANT'S SIGNATURE Title:— \p\ � Date: AUTHCRIZAIION 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 and/or �1;environmental/site assessment information to SAN JOAQUIN COUNTT PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon a$ (,t it is available and at the sa time it is provided to me or my representative. ee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check 0 Recvd By RENS SUPV _/_J ACCT i UNIT CLK --j- 0 —j_