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T GENERAL PROGRAM FILE <br />New A— Change Edit Is (PROG3) revised 5/21/93 <br />FACILITY ID it 72 6 - FACILITY NAME <br />but l voca-h ci -ba) <br />RECORD ID # ��Z PRIOR SWEEPS/COMP # 46, =moo <br />DAIRY: Grade A Grade 8 Milk Dispenser <br />FOOD: Restaurant Narkeft Commissary _ <br />Seating Capacity Sq Ft <br />Temporary Food Facility Special Food Event _ <br />Food Vehicle Make License # <br />HAZARDOUS WASTE: Tons Generated/Yr <br />_ HOUSING: Hotel/Motel No. of Units <br />Employee Housing No. of Employees <br />_ LIQUID WASTE: Pumper Vehicle Pumper Yard <br />Number of Containers in Multi -Head Unit <br />_ Mobile Food Produce Stand Ice Plant <br />Market w/Food Prep: Y / N <br />Vending Machines Number of Vending Units <br />Registration # Color <br />TIERED PERMIT Facility CA CE PBR <br />Jail/Exempt Institution Housing Abatement <br />Approx Dates of Occupancy _ / / to <br />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: RWQCB DTSC NPL Site RB/H20 Q 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 Kennel <br />EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br />CONTACT 1 : <br />CONTACT 2 : ( ) <br />DESIGNATED EMPLOYEE # <br />1�y <br />8 <br />PROGRAM ELEMENT # <br />S 3 <br />CURRENT STATUS <br /># OF UNITS : <br />EPA IDU #: <br />7- q0 i7L- <br />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/EHO 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 JOAQUIN 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 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. ! n 10. ^ 1) 7 7 L4 i <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # Check # <br />Recvd By <br />7- q0 i7L- <br />RENS _/_J SUM/ _/_J ACCT �_L_J q 6 UNIT CLK _ �_/ <br />