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.� NERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # 731& <br /> / C <br /> FACILITY NAME � � <br /> RECORD ID # Q4 D C/ PRIOR SWEEPS/COMP # ll <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 Ft 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: Hotet/Motel No. of Units Jait/Exempt Institution Housing Abatement <br /> Employee Housing No, of Employees Approx Oates of Occupancy _/_/ 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 Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 Q Other <br /> AX <br /> _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Wa"e1ERt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor i#� <br />� �UN1 "� <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds .Kennel ,"AiV J`Ji' <br /> nrCQ <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY PU8L rrrH ¢c'H DIVISIrt' <br /> rNVIRONMENTAL <br /> CONTACT 1 : ( ) C ) <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE # c)(9 PROGRAM ELEMENT CURRENT STATUS <br /> # OF UNITS : EPA ID #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: L, 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 form. I also certify that I have prepared thisapplication 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 <br /> Title: Date: <br /> AUTHORIZATION 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 /> 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. � , U�� 7-2 7 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> IL-71 qC. <br /> RENS _/_� SUPV _� / A c _LZI UNIT CLK _! / <br />