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GENERAL PROGRAM FILE : New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # ;7�Cj FACILITY NAME�i0PJ GSE G ie� � <br /> �y <br /> RECORD ID # �% 5�6�3 /� PRIOR SWEEPS/COW # l1 flC� <br /> —L- -E <br /> DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Nulti-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 !fake 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 Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy / to <br /> LIQUID WASTE: Pumper vehicle Pumper Yard Chemical Toilets NO. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Ski(ted Nursing Lg Generator Sm Generator <br /> Storage (2-10) ,,,,.,_,_ Storage (11-50) _ Storage C --50 ) Transfer StaLtd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Poot Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAA Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCS DTSC NPL Site Re/H20 Q Other <br /> I <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # �V� PROGRAM ELEMENT # s �-� CURRENT STATUS <br /> 9 OF UNITS v 'NEPA ID #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, 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 this application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAQ1JIN 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 alt results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIW 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 /> RENS _/,f SUPV � � ACCT 7 / f-67UNIT CLK �_� <br />