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GENERAL`PROGRAM FILE New _0 Change Edit v� i (PROG3) revised 5/21/93 <br /> FACILITY ID # X3"1 FACILITY NAME <br /> RECORD ID # M /JJ PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A ll.•ll— 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 Machines — Number of Vending Units <br /> Food vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE — PBR — <br /> _ HOUSING: Hotel/Motel — No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing — No. of Employees Approx Dates of Occupancy _f_/— to <br /> LIQUID WASTE: 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 Sta _ Ltd Hauler _ Vet Clinic <br /> _ RECREATIONAL HEALTH: Pool/Spa — Number of Poo <br /> Ls Out of Service Pool — Natural Bathing Place — <br /> SITE MITIGATION: Environ Assess — UST/CAP ✓ Loc Haz Waste _ Haz Mat PPL — <br /> Other Lead Agency Site — Agency: RWQCB — DTSC — NPL Site — RB/H20 0 — Other — <br /> _ SOLID WASTE: Landfill Transfer Ste — Recycling Fac — Waste Storage Fac — Ag Waste/Exempt Site — <br /> SW Vehicle _ No. Dumpster — No. Stationary Compactor Site — <br /> VECTOR CONTROL: Poultry Farm — Max Number of Birds Kennel — <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 : <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # ZG�lJ' CURRENT STATUS <br /> # OF UNITS : EPA ID #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. 1 also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <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 the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the sane time it is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> UNIT <br /> REHS _/_/_ SUPV �/ / ACCT /` CLK <br /> L, <br />