Laserfiche WebLink
GENERAL PROGRAM FILE New <br /> • Change Edit • (PROG3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR SWEEPS/CCMP # <br /> _ DAIRY: Grade A — Grade B — Milk Dispenser — Number of Containers in Multi-Head Unit <br /> _ F00D: 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 <br /> License # Registration # Color <br /> _ HAZARDCUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE — PBR — <br /> HOUSING: Hotel/Motel — No. of Units Jail/Exempt Institution Housing Abatement <br /> A ox Dates of Occupancy �_/— to _/_/— <br /> Employee Housing — No. of Employees PPI' <br /> Yard — <br /> _ LfoUlO WASTE: Pumper Vehicle — PumperChemical Toilets — No. Package Tx Plant— <br /> MEDICAL WASTE: Primary Care _ Acute Care Skilled Nursing — Lg Generator — Sm Generator Sta — <br /> Storage (2-10) Storage (11-50) _, Storage ( >50 ) Transfer _. Ltd Hauler Vet Clinic <br /> 1[ RECREATIONAL HEALTH: Pool/Spa ,_, Number of Pools Out of Service Pool — Natural Bathing Place — <br /> /` SITE MITIGATION: Environ Assess _ UST/CAP — Loc Net Waste — Haz Mat PPL — <br /> Other Lead Agency Site __,z Agency: RwoCa '< DTSC ,_ NPL Site — RS/H20 0 — Other — <br /> _ SOLID WASTE: Landfill Transfer Sta _ 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 Kernel — <br /> DAY NIGHT <br /> EMERGENCY NOTiFI L�AT'IONfor/this FACILITY <br /> hisFACILITY and/or PROGRAM <br /> 3 cl <br /> CONTACT 1 : <br /> CONTACT z : CT A Y f VR IL4 F)S (.jLq) <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> # OF UNITS EPA 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 It le SAN JOAQUIN NTY Ordinance Codes and/or standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE <br /> Title:—`+- e — �^`�F Date: D <br /> AUTHORIZATION TO RZLEASE INFORMATION: In addition to the above, when applicab , I, Ahe 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 timre it is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/__/__ SUPV _/_/__ ACCT _/_/_ UNIT CLK _/_�— <br />