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GENERAL PROGRAM FILE am NO <br /> Change Edit (PROM revised 5/21/0 <br /> i <br /> FACILITY <br /> FACILITY ID # C <br /> RECORD 1D # _ CJ ��3 PRIOR SWEEPS/COMP # <br /> i <br /> DAIRY: Grade A Grade S Milk Dispenser Number of Containers in MuLti•Head Unit <br /> _ FOOD: Restaurant Market CamoissaryMobile 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 Nulber of Vending,Units <br /> Food Vehicle Make License# Registration # Color <br /> HAZARDWS WASTE: Tons Generated/Yr; TIERED PERMIT Facility:- I CA _I .CE Pak <br /> HOUSING: Hotet/Motel. No.. of Units Jail/Exempt Institution + "M irg Abatement <br /> Employee musing No. of EmployeRs Approx Oates of Occupancy f to <br /> LIQUID WASTE: Pumper Vehicle Punper Yard_ Chemical Toilets No_ Package Tx Plant <br /> _ 14EDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg G"rator Sm Generator <br /> Storage (2-10) _T` Storage (11-50Storage ( ASO ) Transfer Sta _' !td Haler vet Clinic <br /> /} CREATIONAL HEALTH: POOL/Spa Meer of Pools Out of Service Paol Nalxlral Bathing Place <br /> ' SITE MITIGATION: Environ Assess d /CAP LOC Hat Waste Haz Mat PPL <br /> Other Lead Agency site Agency: RWDCB DTSC NPL Slte Ra/H2O a Other <br /> _ SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste storage Fac �_ A6 Waste/Exeapt Site <br /> SW vehicle No. Dumpster No. $tationar Compactor Site <br /> I <br /> VECTOR CONTROL: Poultry FaMt Max Number of Birds _ xenneL <br /> NIGHT <br /> EMERGENCY NO71fICATION for this FACILITY and/or PROGRAM DAY , <br /> CONTACT 1 - <br /> CONTACT 2 t ) •� ( ) <br /> DESIGNATED EMPLOYEE # �f/�` . PROGRAM ELEMENT # CURRENT STATUS <br /> # OF UNITS EPA ID #y INSPECTION CODE ' l <br /> .. <br /> BILLING and COMPLIANCE A=OWLEDGEMENT: I, the undersigned owner, operator or agent of same, ackno�led9e that all site and/or <br /> project specific PHS/EHO hourly charges associated with this facility or activity WILL he billed to the party identified as the <br /> BILLING PARTY on this forte 1 also certify that I have prepared this application and that the workf <br /> be performed will be done <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and Federal laws. <br /> APPLICANT'S SIGNATURE / �v� '� ' <br /> Title: <br /> �Gv Date: <br /> = !` c- r; <br /> AUTHORIZATION TO RELEASE INFORMATION: ` n:addition to the above, when applicable, to the owner, aperJator Or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all resutts, Igeotadmieal dots and/or <br /> environmental/site assessment information.to:SAN .IOAOUIN COUNTY PUBLIC HEALTH SERVICES EHVIRONMENTAII HEALTH DIVISION as 600n. 2s <br /> it is available and at the sale time it i$ provided to me Or my representative. <br /> Fee Amount Mount ilia d Date of Payment Payment Type Receipt t� Ctleck a Recvd BY <br /> RENS ��/_� ACCT _/ UNIT CLX <br /> I <br /> Z0'd EV0021ZZSTPI 0i WONJ WdSO:20 S66I—L0—b0 <br />