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1 / <br /> GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/18/93 <br /> FACILITY ID # FACILITY NAME <br /> mL <br /> RECORD 1D # I l 515 PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A _111 Grade 8 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 N/Food Prep: Y / N Number of Vending Machines <br /> Food Vehicle _, Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ PBR <br /> _ HOUSING: Hotel/Motel _ No. of Units Jail/Exempt Institution <br /> Employee Housing _ No. of Employees Approx Dates of Occupancy _/_/_ to <br /> LIQUID WASTE: Pumper Vehicle _ Pumper Yard _ Chemical Toi Lets _ 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 ( >50 > Transfer Sta _ Ltd Hauler _ Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool _ Natural Bathing Place <br /> _7__SITE MITIGATION: Environ Assess UST/CAP _ Loc Haz Waste _ Haz Mat PPL <br /> Other Lead Agency Site _ Agency: RWQCB DTSC _ NPL Site _ RB/H20 Q _ Other <br /> _ SOLID WASTE: Landfill Transfer Sta _ Recycling Fac _ Waste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster _ No. Stationary Compactor Site _ <br /> ite VECTOR CONTROL: Poultry Farm Max Number of Birds KenneL <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM <br /> DAY NIGHT <br /> CONTACT 1 : <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # y- PROGRAM ELEMENT # 5 CURRENT STATUS <br /> # OF UNITS EPA ID #: INSPECTION CODE <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> this form. <br /> I also certify that I have prepay, this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, St a and f raL�aus— <br /> APPLICANT'S SI TURE <br /> �I <br /> Title: Date: <br /> /�?3/�L^�J'/� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when appLicabl , 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 /> SUPV� _/__/__ ACCT _/_-i -- UNIT CLK _/__/— <br />