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Grade B Milk Dispenser DAIRY: Grade A Number of Containers in Multi-Head Unit <br />CE PBR TIERED PERMIT Facility : CA <br />FOOD: Restaurant Market <br />Seating Capacity Sq Ft <br />Temporary Food Facility Special Food Event <br />Food Vehicle Make License # <br />HAZARDOUS WASTE: Tons Generated/Yr <br />Produce Stand Ice Plant <br /> <br />Market w/Food Prep: Y / N <br /> <br />Vending Machines Number of Vending Units <br />Registration # Color <br />Commissary Mobile Food <br />NIGHT <br />DESIGNATED EMPLOYEE # PROGRAM ELEMENT # Z ?. CURRENTSTATUS <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 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. <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />_........., <br />?. .4 <br />, (' <br />,.., , ..._.. --i• \ <br />REHS / / SUPV .1_:_../ ACCT (DI UNIT CLK / / <br />7)—/ _ <br />) n IL <br />GENERAL PROGRAM FILE : <br />no <br />New <br />FACILITY ID # <br />_ <br />FACILITY NAME ski) -,,_,,,,,,, so, Dv , u(d_w q_ <br />RECORD ID # c7, 3(ci 33 PRIOR SWEEPS/COMP # / <br />HOUSING: Hotel/Motel No. of Units <br />Employee Housing No. of Employees <br />Jail/Exempt Institution Housing Abatement <br />Approx Dates of Occupancy / / to / / <br /> <br />LIQUID WASTE: Pumper Vehicle Pumper Yard <br /> <br />Chemical Toilets No. Package Tx Plant <br /> <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 />Change Edit <br /> <br />(PROG3) revised 5/21/93 <br />RECREATIONAL HEALTH: Pool/Spa Number of Pools <br />._/S.ITE MITIGATION: Environ Assess i-/// UST/CAP <br />Other Lead Agency Site Agency: RWOCEI <br />SOLID WASTE: Landfill Transfer Sta Recycling Fac <br />Out of Service Pool <br /> <br />Natural Bathing Place <br />Other <br />Waste Storage Fac Ag Waste/Exempt Site <br />Loc Haz Waste Haz Mat PPL <br />DISC NPL Site RB/H20 <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 <br /> <br />DAY <br />CONTACT 1 : <br />CONTACT 2 : <br />