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PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> f',•„ <br /> �I:ACiLITY ID # FACILITY NAME I 20 — , Y�b <br /> RECORD ID # <br /> PRIOR SWEEPS/COMP # I" V1Z -Z-Z- <br /> ty. ' <br /> DAIRY! Grade A Grade B Milk Dispenser _ Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Cortmissary _ Mobile Food Produce Stand _ Ice Plant _ <br /> Besting Capacity Sq Ft Market u/Food Prep: Y / N <br /> Temporary Food Facility _ Special Food Event _ Vending Machines _ Number of Vending Units <br /> Food Vehicle _ Make <br /> License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ PER <br /> _ HOUSING: Hotel/Motel _ No. of Units Jail/Exempt Institution Housing Abatement <br /> Enployee Housing __ No. of Employees Approx Dates of Occupancy _J_/_ to _/—/— <br /> LIQUID WASTE! Pumper Vehicle Punper Yard Chemical Toilets _ Na. Package Tx Plant- <br /> Ski <br /> MEDICAL WASTE! Primary Cafe `:ACUte Care lled Nurs Sing ' I.§ Generator Sm Generator <br /> iti k Storage (2.10) _ Storage (11.50) Storage ( >50 ,Transfer 5t a',_,_ Ltd Hauler'_ , VetlinlG <br /> RECREATIONAL HEALTH: Pool/Spa _ Number of POOLS Out of Service Pool Natural Bathing Place <br /> ✓ SITE MITIGATION: Environ Assess `� UST/CAP Loc Haz Waste Net Mat PPL <br /> Other lead Agency Site Agency: RWOCS DTSC _ NPL Site _ RS/H20 0 other <br /> _ SOLID WASTE: LarcJfilt Transfer Ste Recycling Fac _ Waste Storage Fac _ Ag Waste/Exempt Site _ <br /> SW Vehicle No. Dumpster No. Steti nary Compactor Site <br /> S <br /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kennel <br /> - EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAM <br /> DAY NIGHT <br /> J4 ) _ <br /> CONTACT 1 1. <br /> CONTACT 2 j ok,uS7---�•✓ <br /> DESIGNATED EMPLOYEE # �- PROGRAM ELEMENT # Zy,J� CURRENT STATUS <br /> # OF UNITS EPA ID #• INSPECTION CCOE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT:.- 1„the undersigned owner, operator.or agent of same, acknowledge that ell site and/or <br /> y ` project specific PHS/EMD hourly charges associated with this facility or activity will be billed to the party identified ba the <br /> '^.BILLING PARTY on this form. 1 also certify that I have prepared this application and that the work to be performed will be done <br /> C lh;' ' in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codas acid/or Standards and State end/or federal laws. <br /> f APPLICANT'S SIGNATURE t <br /> Tittb: .014 LG�e7� 1,51ce0 bate: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above; when applicable, 1, 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 /> 3y0 <br /> SUPV _/_J_ <br /> ACCT _/_/_ UNIT CLK �__/_ <br />