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ID _4" 1i $ 12- - <br /> GENERAL PROGRAM FILE N _ Change Edit (PROG3) revised 5/18/93 <br /> FACILITY ID # f,��y�G�' FACILITY NAME /iST Mo4Nr46k>f�`T aF S7aG�7'�r✓ <br /> RECORD IO # (/� '9�OCQC, PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ic_e Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N Number of Vending-Machines <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution <br /> Employee Housing No. of Employees Approx Dates of Occupancy _/ / to <br /> _ LIOUID 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: RWOCB DTSC NPL Site RB/H20 D Other <br /> _SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle �No. 12— Dumpster No. Stationary Compactor Site <br /> _ VECTOR CONTROL: Poultry Farm Max Number of Birds Kernel I <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT 1 <br /> CONTACT 1 . ( ) C ) <br /> CONTACT 2 . C ) ( ) <br /> DESIGNATED EMPLOYEE # 3"1 f PROGRAM ELEMENT # COCl CURRENT STATUS , <br /> # OF UNITS : 2— EPA ID #: INSPECTION CODE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and 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. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> PP i <br /> REHS // / / °3 SUPV 1/_f— ACCTle�,/ I / 3 UNIT CLK _/_f <br />