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Nov- 18-98 01 : 11P 0 0 P . 02 <br /> GENERAL PROGRAM FILE Mew Change Edit------- (PROG3) revised 5/21/93 <br /> FACILITY 10 1 FACILITY NAMEov <br /> elow <br /> / <br /> RECORD 10 a PRICR SWEEPS/COMP M <br /> _ DAIRY: Grade A _ Grade B _ Milk Dispenser _ Mustier of Containers In Multi-Mead Unit <br /> FOOD: Restaurant __ Market COmmisaary _ Mobf to Food _ Produce Stand _ Ice Plant ` <br /> Seating Capacity Sq Ft Market w/Food Prep. Y / N <br /> Temporary Food Facility _ Special Food Event _ vericinq Machines _ Number of Vending Units <br /> Food Vehicle _ Make License R Registration t Color <br /> HAZARDCU3 WASTE: Tons Generated/yr TIERED PERMIT Facility : CA ` CE FSR <br /> HOUSING: Notel/Motel _ No. of Units _ tai L/Exem;t Institution Housing Aboiement _ <br /> Employee Nasing ` N0. of Employees Approx Dates of OccupenLy _J_/_ to <br /> _ LIQUID WASTE: Pumper Vehicle _ Puper 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 C •50 ) — Transfer Sts _ Ltd Hauler Vet Clinic <br /> RE:REAT!ONAL HEALTH: Poo L/Spa Nurber of Pools Out of Service Pool Natural Bashing Place _ <br /> :ITE MI'IGAT:ON: Environ Assess UST/CAP Loc Het Waste _ Maz Mat PPL _ <br /> other Lead Agency Site _ Agency: RWOCB OTSC _ NPL Site _ RB/H20 0 Other <br /> SOLID WASTE: Landfill Transfer Ste _ Recycling Fee Waste Storage fae _ Ag Waste/Exempt Site <br /> SW Vehicle No. Ouq:ater _ Mo. Stati artery Compactor site <br /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kemal <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 : q e f�✓�UtJ Z §L7. L 3 <br /> CONTACT 2 : __ f LC. �/L/c.,A:. ( ) -�- (�) L y - } 4 <br /> L <br /> DESIGNATED EMPLOYEE k PROGRAM ELEMENT k SD CURRENT STATUS <br /> 0 OF UNITS : EPA ID M: 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/EMO hourly charges associated with this facility or activity will be hilted to the party identified as the <br /> BILLING PARTY on this form. I also certify that I have prepared this sppticat'm and that the work to be performed will be done <br /> in accordance with all apolicable,SAN JOAQUIN COUNTY Ordinance Codes and/or Standards end State and/or Federal Laws. <br /> {r . <br /> APPLICANT'S SIGNATURE <br /> Date. /�-i o - / J <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when appL icable, I, the owner, operator or agent of seem, of <br /> the property located at the above site address hereby authorize the reisase 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 rte or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt M Check a Rocvd ay <br /> 0-0 <br /> RE5S �� /�/� SUPV _/ /_ ACCT / UNIT -LK <br />