Laserfiche WebLink
GENERAL PROGRAM FILM t Now Change Edit (PR003) revised 5/21/93 <br /> FACILITY 10 0 FACILITY NAS! <br /> RECORD iD 0 PRidt INREPl/Camp <br /> DAItIYt Orad* A Grob R milk Dispweutr ,"_,, :WAdw of Containers In Multi-Need Unit <br /> FOODt Restaurant flarket Comis*ery Mobile Food Produce Stand fee Plant <br /> leatinq Capacity Sq Ft Market Wood Prep: Y / N <br /> Temporary Food Feel IIty Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License M Registrattori A color <br /> HAZARDOUS UASTIEt Tote Generated/Yr TiERED PERMIT Facility % CA CE POR <br /> _ MOUSING% Notel/Notel No. of Units Jsil/Exempt Institution Nousing Abatement <br /> Esployea NowIng NO. of Employees Approx Dates of Occupancy __J_I_ to _>>J <br /> LIQUID WASTE% Pumps; Vehicle Ptmnper yard chefflieal Toltete No. Pecks" Tx Plant <br /> T MEDICAL VASTER Primary Care Acute Care Skilled Nursing Lg Generator Se Generator <br /> Store" (2.10) ^_ Storage (11-50) _ Store" ( >50 ) ^ Transfer Ste Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Nunber of Pools Out of Service Pool Matural Bathing Place <br /> X SITE MITIGATION: Environ Assess X UST/CAD Loc Hes haste Hai Mat PPL <br /> "or Lead Agency lite Agency: RWQCB X DTSC NPL Site 0/020 Q Other <br /> SOLID WASTE% landfill Transfer its Recycling Fee Waste Storage Fae Ag Waste/Exempt Site <br /> SW Vehicle No. Otip4ter No. Stationary Caepector Site <br /> VECTOR CONTROLt Poultry Farts Mex *m ber of Birds Kernet <br /> c�a e <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAT NIGHT <br /> CONTACT i't TIM BERGER ( 916) 863 - 9323 ( 916) 863 -9 323 _ <br /> CONTACT 2 . LARRY KLEINECKE (Q16) 962 - 1612 ( 916) 962 . 1612 <br /> 0010 160 E)MLOYEi / (Q � PROGRAM ELEMENT ! CURRENT STATUC <br /> l Of UNITS i EPA ID B: INSPECTION CODE : <br /> llttiNG aid CaNPl1AM ACKNOHLEDOBtENT% 1, the undersigned owner, operstoe or agent of same, acknowledge that all site Wwor <br /> project spaclfic PMS/END hourly charges associated with this facility or activity will be billed to the party Identified as the <br /> 11ttING PARTY on this fore. l also certify that f have prepared this application and that the work to be perfors d will be dote <br /> In accordsne* with all applicable SAN JOAG"N COUNT �Ordinance Codes and/or Standards and State and/or Federal lawn. <br /> APPLiCANTP! 21alATlAf t <br /> Titles <br /> SENIOR GEOLOGIST Date: <br /> Page /Or <br /> AUTHORIZATION TO RELEASE INFOWTIONt 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 retesse of any and all results, geotechnical data and/or <br /> environow tat/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL NEALTR DIVISION a soon as <br /> It Is available and at the tame time it is provided to me or my representative. <br /> fee Amount Amount Paid Dote of Payment Payment Type Receipt it Check If Rec-W By <br /> �z <br /> RENS j I / SUPV �! / ACCP _/ UNIT CLK _J / <br />