COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

GENERAL PROGRAM FILE New Change Edit (PROM) revised 9/21/93 FACILITY ID # !�� FACILITY NAME RECORD ID # Ae ®7 PRIOR /COMP # DAIRY-- Grade,A Grade B MiLk Dispenser - Number,of Containers in MuLti-Need Unit FOOD: Restaurant Market Commissary Nobite Food Produce Stand Ice Ptant Seating. ity Sq Ft Market-Wood Prep: Y / N Temporary Food Facitity Speciat Food Event Vending Machines Number of Vending Units Food vehicle Make License# Registration # Color HAZARDOUS WASTE: Tots Generated/Yr TIERED PERMIT Facility CA CE PBR HOUSING Hotel/Motet No. of Units Jail Institution Housing'Abat Employee Housing No. of EmPtaYeas Approx Dates of 0=4wcy � / / to LIQUID WASTE-- Pumper Vehicle puqw Yard chemicat Tai Lets No. T% Ptant MEDICAL BASTE: Priaoery Care Acute Care Milled Nursing Lg for for Storage (2.10) Storage (11-50) Storage t >90 ) _„ Transfer Ste _ td Hooter , et Ctinic RECREATIONAL HEALTH: Poot/Spa Number of'Poots out of Service Perot; Naturst Bathing Ptace SITE MITIGATION: Environ Assess UST/CAP Loc Naz ,Waste Hat Mat PPL Other Lead Agency Site Agency: RWOCS Disc NPL Site RB 4 Other SOLID WASTE: Landfitt Transfer$to Recycling Fec haste Storage Fac Ag Wnte/Exempt Site SY Vehicte No. Oumpater No. Stationary Compactor Site VECTOR CONTROL: Pouttry Farm Max Number of Birds Kennet EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 ( ) f ) CONTACT 2: ( ) { ) DESIGNATED EMPLOYEE# PROGRAM ELEMENT it (� STA7119 # OF UNITS : EPA ID #- INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT-- I,. the'undersigned owner, opwator, or agent of sow, t that att sits and/or project specific PNS/EHO how ty charges associated with this facility or activity mitt be bitted to party,identified:as the BILGING PARTY on this form. I atso certify that I haw prepared this.applicatiorn'and that the to be performed wilt be done in accordance with alt applicable SAN JOAQUIN COUNTY Orth and/or Standards and'State andlor Federal Laws- APPLICANT'S SIGNATURE x Titte: Date: AUTHORIZATION TO RELEASE INFORMATION: Inadditionto the above, when appticabte, I, the , operator or agent of same,, of the Property located at the above site address hereby authorize the retesse of any and alt resuLts, geotechnicaL data and/or enviromortat/site assessment informatim to.SAN JOAQUIN COUNTY PU13LIC HEAL11 SERVICES ENVIRONMWAL HEALTH DIVISION as-soon as it is avaitabte and at the same tic* f t is provided to me or my representative- Fee Amount Amount Paid Date of Payment PsYment` Type Receipt Check # Rewe By SUN __J_ ,_f'' ACCT