Laserfiche WebLink
r;FNfRAL PROGRAM FILE New Change Edit (PROG3) revised 8/76;03 <br /> F,77, 7Y ID # evJr t �j FACILITY NAME <br /> RECORD ID # /,��a) ccJJ� PRIOR SWEEPS/COMP 0 <br /> DAIRY: Grade A CJ 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 Ft Market w/Food Prep- Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Foul Vehicle Make License # Registration # Color <br /> ` HA7AR000S 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 Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Naz Mat PPL <br /> Other Lead Agency Site Agency: RWOCB DTSC NPL Site RB/H20 0 Other <br /> SnLTD WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Durpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> FMFPGFNCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 2 ( ) ( ) <br /> DESIGNATED EMPLOYEE # Lo PROGRAM ELEMENT # / CURRENT STATUS <br /> V OF UNITS EPA ID aY: INSPECTION CODE <br /> BILLING aril COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> projAct specific PHS/END 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 dorso <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> YAPPtICANTIS SIGNATURE <br /> K.,i tln:—Kate: <br /> UTHORI7ATION 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 /> envirorvnrntal/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 /> M <br /> c?F HS / / SUPV / / ACCT _ Ll/_ _��/ 9 UNIT CLK / / T <br />