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f,ENERAL PROGRAM FILE New Change Edit _ (PROC3) revised 5/21/93 <br /> FACILITY ID Nrrn FACILITY NAME 5yebp� COr pyo - _------ <br /> RECORD ID N W O vl PRIOR SWEEPS/Comp N — <br /> _ DAIRY: Or" A Grade R Milk Dlspeneer — Number of Containers In Multi-Heed Unit <br /> _ ra00: Restaurant Market — Commissary __ Mobile rax( _ Produce Stand _ lee Plant <br /> Seatlnp Capacity sq Ft Market w/food Prep! Y / N <br /> TmtT rary Food Facility _ Special Food Event _ Vendhy Machines _ Number of Vending Units <br /> Food vehicle _ Make Licrose N Registretlo,i N Color <br /> HAZARDOUS WASTE: Tons Generated/Ys _ TIERED PERMIT rlcllity - CA _ CE — FOR <br /> _ HOUSING: Hotel/Motel _ No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing _ No. of Esployees —__— Approx Dates of Occupancy _/_/_ to --J <br /> LIQUID WASTE! Pumper Vehicle — PLx"r Yard Chemical Toilet" — 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 ) Trmsfer Ste _ Ltd Hauler _ Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Nudger of pools __ Out of Service Pool _ Natural Bathing Place — <br /> SITE MITIGATION: Environ Assess UST/CAP 75�— Loc Hez Waste _ Haz Met PPL <br /> Other Lead Agency Site _ Agency! RWOCR _ Disc NPL Site _ RB/1120 O — Other — <br /> _ SOLID WASTE! Landfill Transfer Ste _ ReeyeUng FPC Waste Storage Fac _ Ag Wsate/Exellpt Site <br /> SW Vehicle _ No. 0umpa[er No. Stationary Compactor Site <br /> VECTOR CONTROL- Poultry Form _ Max Number of Birds Kennel _ <br /> EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAM DAY NIGHT <br /> CONTACT 1 t <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE IF 2 PROGRAM ELEMENT N 5'b CURRENT STATUS <br /> N OF UNITS I EPA ID N: INSPECTION CODE <br /> BILLING and COMPL MINCE ACKNOWLEDGEMENT: 1, the undersigned Omer, operator or agent of same, acknowledge that all site end/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. I alsrtify that I have prepared this application and that the work to be performed will be dons <br /> In accorderncs with sit applicabLeVANJOAQUIN C TY Ordinance Codes id/or Standards and State and/or Federal laws. <br /> APPLICANTS SIGNATURE <br /> Page1011 <br /> Title: \ \`K S\(�`�1� � 1 i--�� Date- <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> tl,e preperty'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 et the as" time It Is provided to me or my representative. <br /> Fee Amxxnt Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> ?�C) CL <br /> REHS _/__/__ SUPV _/_/__ ACCf —�L4/ UNIT CLK _/ /— <br />