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(PROG3) revised 5/21/43 <br /> GENERAL PROGRAM FILE New Change Edit <br /> FACILITY ID # }�O 7 FACILITY NAIL j! <br /> �✓ <br /> RECORD ID # PRIOR SWEEPS/COMP # u <br /> DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers!in Mutti-Heed Unit <br /> _ FOOD: Restaurant Market commissary Mobile Food Produce Stand ]ce 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 # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> HOUSING: HoteL/Motei No. of Units Jail/Exempt Institution Housing Abatement <br /> _ Employee Housing No. of Employees Approx Dates of OccupaJ_J to —J._.__J <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets '; No. <br /> rPackage Tx Plant <br /> a I <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 /> 1, SITE MITIGATION: Environ Assess L- UST/CAP Loc Haz Waste H Mat PAL <br /> Other Lead Agency Site Agency: RUQC8 DTSC NPL Site 28/H20 4 Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste StarIl1ge Fac Ag Waste/Exempt Site <br /> �. SW Vehicle No. Dumpster No. h Stationary Compactor Site <br /> - VECTOR CONTROL: Poultry Farm Max Number of Birds iKennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM I DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 <br /> r <br /> DESIGNATED EMPLOYEE # Vqf 1 PROGRAM ELEMENT # If 5� CURRENT STATUS <br /> # OF UNITS EPA ID #: INSPECTION CODE Z� <br /> u <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 alnd that the work to be performed will be done <br /> in accordance with all applicable SAN JOAWIN COUNTY Ordinance Codes and/or Standards and State and/or Federal. laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, [1k 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 ,� Rece{�ipt # Check # Recvd By <br /> IE <br /> ACCT / UNIT CLK <br /> RENS �/ / 5U ,�_� --�-- <br /> -. - - <br />