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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME <br /> I <br /> RECORD ID # PRIOR SWEEPS/COMP # i <br /> i� <br /> I DAIRY: Grade A Grade H Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary 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 />!I Food Vehicle Make License # Registration # Color <br /> I <br /> It <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility CA CE PBR ) <br /> _ HOUSING: Notel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates ofloccupaicy,_f / tof____ f <br /> . LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets, No. Package Tx Plant <br /> l� a <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator 5m Generator <br /> Storage (2-10) Storage (11-50) _ Storage { X50 ) Transfer Sta Ltd.,Hauler Vet Clinic <br /> RECREATIONAL HEALTH: PooL/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> ITE MITIGATION: Environ Assess '� UST/CAP Loc Naz Waste P Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC !lNPL Site RB/H20 Q Other . <br /> ;f <br /> I , SOLID WASTE: Landfill Transfer Ste Recycling Fac waste Storage Fac Ag Waste/Exempt Site } <br /> i SW Vehicle No. Durpster No. Stationary Compactor Site <br /> Ie1 <br /> E VECTOR CONTROL: Poultry Farm Max Number of Birds �3R j Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br />' CONTACT z - <br /> f DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> N OF UNITS EPA ID #: �p INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator 'ar agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the <br /> BILLING PARTY on this form. I also certify that I have prepared this applieation.and that the work to be performed will be done <br /> in accordance with all applicable SAN JQACUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal taws. <br /> APPLICANT'S SIGNATURE <br /> i <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicabie, Ii 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 /> !{ i <br /> if <br /> REHS ___� / / SUPV I_..� ACCT ���/ / UNIT CLK _/ / <br />