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1 <br /> GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME <br /> 5�oZ FACI <br /> TO RECORD ID # SV W 8 PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in multi-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ftp 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 J / 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 Pools Out of Service Pool Natural Bathing Place <br /> V/ SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWRCB DTSC NPL Site RB/H2O fl Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. D►mpster 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 /> 5-3COCONTACT 1y AE)91�'� (45}_�ftL�j 12S-3- <br /> CONTACT <br /> NTACT 2 <br /> DESIGNATED EMPLOYEE # OC�� PROGRAM ELEMENT # 2C� s o CURRENT STATUS <br /> # OF UNITS EPA ID #: INSPECTION CODE® <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, 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 bitted to the party identified as the <br /> BILLING PARTY on this form. I 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 a <br /> Title GII� nm t�Pt° Date: <br /> AUTHORIZATION TO RELEASE INFORMATION In addition to the above, when applicable, 1, 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 same time it is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS / / SUPV �/ / ACCT <br /> `tt <br />