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-GENERAc PROGRAM FILE : New _ Change Edit (PROG3) revised 5/21/93 FACILITY ID # 00 SS�Q FACILITY NAME RECORD ID # �.7 93 1 PRIOR SWEEPS/COMPI# DAIRY: Grade A Grade a Milk Dispenser Number of Containers in Multi-Head Unit FOOD: Restaurant Market Commissary _ Mobi Le Food _ Produce Stand _ Ice Plant Seating Capacity Sq Ft Market u/Food Prep: Y / N Temporary Food Faci Lity _ Special Food Event _ Vending Machines _ Number of Vending Units Food Vehicle Make License # Registration # Color HAZARDOUS WASTE: Tons Generated/Yr �. f- TIERED PERMIT Facility : CA _ CE _ PBR HOUSING: Hotel/MoteL No. of Units Jai L/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 Ski Lled Nursing _ Lg Generator _ Sm Generator Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) _ Transfer Sta _ 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 Hat Waste Haz Mat PPL Other Lead Agency Site _ Agency: RWOCB DTSC NPL Site _ RB/H20 Q _ Other SOLID WASTE: Landfill Transfer Sta _ Recycling Fac Waste Storage Fac _ Ag Waste/Exempt Site SW Vehicle _ No. Dempster _ No. Stationary Compactor Site I VECTOR CONTROL: Poultry Farm _ Max Number of Birds KenreI _ EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 : CONTACT 2 : DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS # 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 project specific PHS/EHD hourly charges associated with this facility, or activity WILL be bi Lled 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 donne in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION 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 ail results, geotechnicaL data and/or anvirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the some time it is provided to me or my representative. Fee Amount Amount Paid Date of Payment Payment TypeReceipt # Check # Recvd By SUPV _/_/_ ACCT UNIT CLK _/_/_