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r <br /> I GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/18/93 <br /> FACIL�TY ID # FACILITY NAME /Af1Q��E � ,J��/L� <br /> RECORD ID # PRIORQSWEE P # =—7 <br /> _ DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit !! <br /> _ FOD: Restaurant Market Commissary Mobile Food Produce Stand Ic_e Plant <br /> Seatillq Capacity Sq Ft Market w/Food Prep: Y / N Number of Vending;Machines <br /> Fod Vehicle Make License # Registration # Color <br /> _ HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility CA CE PSR <br /> i <br /> HOWSING: Hotel/Motel No. of Units Jail/Exempt Institution <br /> E�ployee Housing No. of Employees Approx Oates of Occupancy _/ / to <br /> _ LIOID WASTE: Pumper Vehicle Pumper Yard 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 DISC NPL Site RB/H20 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 /> _ VE TOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGE Y NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> r� <br /> CONT, CT 1 ( ) ( ) <br /> CONVICT 2 <br /> DESI TED EMPLOYEE # jr PROGRAM ELEMENT # 33 CURRENT STATUS y.L <br /> # OF NITS : EPA ID #: INSPECTION CODE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHO 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 /> APPLICAN TIS SIGNATURE <br /> I <br /> Titter 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 /> Fed Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS SUPV _/_� ACCT /__J UNIT CLK _/_J <br />