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'� �✓ Change Edit (PROG3) revised 5/21/93 <br /> GENERAL PROGRAM FILE New <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR SWEEPS/COMP # <br /> _ DAIRY: Grade A Grade B Milk Dispenser __ Number of Containers in Multi-Head Unit <br /> _ <br /> FOOD: Restaurant Market Commissary <br /> Mobile Food _ Produce Stand __ Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N <br /> Special Food Event _ Vending Machines _ Number of Verding Units <br /> Temporary Food Facility __ peC Registration # Color <br /> Food Vehicle __ Make License # <br /> _ <br /> HAZARDOUS WASTE: Tons Generated/Yr <br /> TIERED PERMIT Facility : CA __ CE _ PBR <br /> _ <br /> HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employees <br /> Approx Dates of Occupancy _/_—/— to <br /> Employee Housing __ No. of <br /> _ <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard _ Chemical Toilets <br /> NO. Package Tx Plant <br /> MEDICAL WASTE: Primary Care __ Acute Care <br /> Skilled Nursing __ L9 Generator _,_ Sm Generator <br /> Storage (2-10) <br /> Storage (11-50) Storage C >50 ) Transfer Sta _ ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa _ Number of Pools Out of Service Pool __ Natural Bathing Place <br /> ITE MITIGATION: Environ Ass s _ UST/CAP _/Loa Haz Waste NPL SiMat Mat PPLR— <br /> D Other _ <br /> —ZS <br /> Other Lead Agency Site <br /> Agency: RWOCS ✓ DTSC __ <br /> SOLID WASTE: landfill Transfer Sta Rerycling Fac Waste Storage Fac Stationary WCompactorr Sitemte <br /> SW Vehicle <br /> No. DuiQster __ MO. <br /> _ VECTOR CONTROL: Poultry Farm Max Number of Bunds <br /> Kernel <br /> DAY NIGHT <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM <br /> CONTACT 1 : <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE # <br /> PROGRAM ELEMENT CURRENT STATUS <br /> INSPECTION CODE <br /> # OF UNITS EPA ID #- <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 will be tdone <br /> he <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards aro State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, ° <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirorimental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Fee Amount <br /> Amount Paid Date of Payment Payment Type Receipt # Check # Recvd BY <br /> REHS SUPV <br /> ACCT _/�/_� UNIT CLK _f—.—�— <br />