Laserfiche WebLink
GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID R _— FACILITY NAME —�— '— -- --- <br /> RECORD ID 1 PRIOR SWEEPS/COMP N <br /> DAIRY- Grade A _ Grade D Milk Dfspenser Number of Containers In Multi-Heed Unit <br /> _ FOOD: Restaurant _ Market Commlssary _ Mobile rood Produce Stand _ ice Plant <br /> SestIrV Capacity Sq Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility _ Speclnt Food Event ___ Vending Machines — Number of Vending Unita <br /> Food Vehicle Make Llcense N Registration N Color <br /> HAZARDOUS WASTE: - Tons Generated/Yr _ TIERED PERMIT fncfifty a CA _ CE _ FOR _ <br /> HOUSING: Hotel/Motel _ No. of (Ants Jail/Exempt institution Housing Abatement <br /> Employee Housing _ No, of Employees Arrrox Dates of Occupancy _/ /_ to ___j— <br /> LIOUID WASTE: Pumper Vehicle Pumper Yard Chrmicel Tollete 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 ) Tronafer Sto _ Ltd Hauler _ Vet Clinic <br /> _ RECREATIONAL HEALTH: Pool/Spa _ Number of roots Out of Service Pool _ Natural Bathing Place <br /> SITE MITIGATION: Environ Assess X UST/CAP Loc Haz Waste Hez Met PPL _ <br /> Other Lead Agency Site _ Agency: RWOCR DISC NPL Site _ RB/1120 0 _ Other _ <br /> A_ SOLID WASTE: Lardflll Transfer Ste Recycling Fee Waste Storage Fee _ Ag Waste/Exert Site <br /> SW Vehicle No. Dur"ter No. Stati wary Conpector Site _ <br /> VECTOR CONTROL: Poultry Form _ Max Number of Blyda Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1't Rene Noriega _ (40882 • 9140 (_) <br /> CONTACT 2 : Maria Solis t_510) 287 . 1358 (_) <br /> DESIGNATED EMPLOYEE N PROGRAM ELEMENT N CURRENT STATUS <br /> M OF UNITS : 1 EPA ID N: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. 1 also certify that I have prepared this application and that the work to be performed will be donne <br /> in accordance with all applicable N=,JOAQUIN COUNTY Ordff nce Codes mrd/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE\:� �( v <br /> Page 1011 <br /> Title: PrCYiPet ' Mana�ar—F.nv �RAn ESCC Oete:19-7F-4(i. <br /> T <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the prerwrty located at t`t abavo site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental{site assessment information to SAN JOAOUIN 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 m1' representative. <br /> Fee A�jmount Amount Paid Date of Payment Payment Type Receipt M Check N Recvd By <br /> 2 (Iqu .6v 2 2'1 l� •10 �i lit/ <br /> REHS / / °�I� SUPV _/__/ ACCT _/ /_ UNIT CLK _/ /_ <br />