Laserfiche WebLink
ZENERAL PROGRAM FILE New Change Edit (PQ OG3) revised 5/18/93 <br /> FACILITY ID # •FACILITY NAME +LL <br /> RECORD ID # 4 PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade 8 / 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 Number of Vending-Nachines <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 Jsil/Exempt Institution <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 Skilled Nursing L9 Generator Sm Generator <br /> Storage (2-10) — Storage (11-50) _ Storage ( >50 ) _ Transfer Sts _,_ 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 /> Grn L4q'SO <br /> SOLID WASTE: Lardfilt �C Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> Sit Vehicle No. Duapcter No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kernel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 < ) ( ) <br /> CONTACT 2 : ( ) ( ) <br /> DESIGNATED EMPLOYEE # () fa PROGRAM ELEMENT # cf(r, 3e CURRENT STATUS <br /> # OF UNITS EPA I0 #: INSPECTION CODE <br /> BILLING ACKNOWLEDGEMENT: 1, 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 alt 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 /> SUPY _�/ ACCT / UNIT CLK _f�� <br />