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GENERAL PROGRAM FILE New Change Edit _ rr (PROD) revised 5/21M <br /> FACILITY 10 N � FACILITY MIL AjL5(`QG( <br /> RECORD IO RPRIOR SWEEPS/COMP U <br /> r <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ F000: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: T / N <br /> Temporary Food Facility Special Food Event Vending Machines Nurber of Vending Units <br /> Food Vehicle Make License 0 Registration 0 Color <br /> i <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: HotelMotal No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Eap(oyees Approx Oates of Occupancy _/_f to _f_f <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing LV Generator 4a Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) _ Transfer Ste _ Ltd Hauler _ Vet Clinic <br /> _ RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Max Nat PPL <br /> Other Lead Agency Site Agency- RUQC6 DISC NPL Site RS/H2O 4 Other <br /> _ SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exampt Site <br /> Sul Vehicle No. Oumpator No. Stationery Comp*ctor Site <br /> VECTOR CONTROL: Poultry Fara Max Number of Birds Xewl <br /> EMERGENCY NOTIFICATION for this FACILITT and/or PROGRJW OAT NIGHT <br /> CONTACT 1 : t CAPE biv- (moo)615 2 -q-500 (310)qle S <br /> CONTACT 2 r` G M C r 611;D �3 ( ) - <br /> 0ES(GNATED EMPLOYEE x r _ PROGRAM ELEMENT 0 i CURRENT STATUS <br /> Y OF UNITS EPA 10 U: tNSPECTiOX CODA <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: t, 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 fors. I also certify that I have prepared this application and that the work to be perforiwd 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- Oat*: <br /> AUTHORIZATION TOR EASE INFORMATION: In addition to the above, when applicable, I, the owner, ""tar or agent of saes, of <br /> the property located at the above site addr*ss hereby authorize the reless* of any and all results, geotachnical 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 some time it is provided to me or my representative. <br /> Fee Amount Amount Paid Dace of Payment Pr mmc Type Rec*ipt 9, Check 2 R*cvd By <br /> REHS ACCT a UNI-P.Mx <br />