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.� <br /> J <br /> 461'NERAL PROGRAM FILE ; <br /> New Change Edit <br /> —�— (PROG3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME <br /> Gatewa Center APN I77-040-17 <br /> RECORD ID # 1!J + PRIOR SWEEPS/COMP # <br /> I I <br /> DAIRY: Grade A Grade B E I <br /> Milk Dis '� <br /> penser Number of Containers in Multi-Head Unit <br /> _ FOOD: Restaurant Market Commissar 41 <br /> y 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 ` License # ' <br /> „ Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yrrte~ <br /> TIERED PERMIT Facility : CA CE PBR <br /> 11 <br /> HOUSING: Hotel/Motel No. of Units Jail/Exempt lnstitution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of 6ccupancy / / to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets i No. Package Tx Plant <br /> ij <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 /> :I <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 a Other <br /> �i <br /> I <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 /> it <br /> CONTACT 1 Tim Gagnier (916,) 485 - 8900 { -Same <br /> CONTACT 2 . Mike Gereghty (216'.) 371 0434 (91 6 ) 372—- 7679 <br /> DESIGNATED EMPLOYEE # C PROGRAM ELEMENT # z� �� CURRENT STATUS <br /> # OF UNITS EPIIA.• IO #: 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 rdinance Codes and/or Standards and State and/or Federal taus. <br /> Geotechnical}for Panattoni–Catlin <br /> APPLICANT'S SIGNATURE (Kane <br /> I <br /> Title: Consultinp, Knineer Date:_„ _- <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 roof�jPayment Payment Type Receipt # 11 Check # Rec'vvddd By <br /> f � / V � �O J V 1 � � Y 1 V '✓ / - <br /> REHS / / SUPV ACCT 3/ UNIT CLK �/ / <br />