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* GENERAL PROGRAM FILE New Change Edit • (PROG3) revised 5/21/93 <br /> J FACILITY ID # eS v y FACILITY NAME <br /> RECORD ID # 5�. 3 -..0 PRIOR SWEEPS/CCMP # <br /> DAIRY: Grade A _ Grade B 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 /> 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 Housing Abatement <br /> Employee Housing _ No. of Employees Approx Dates of Occupancy _/ /_ to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard _ Chemical Toilets _ 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 /> SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste _ Haz Mat PPL _ <br /> Other Lead Agency Site _ Agency: RW'OCB DISC NPL Site _ RB/H20 0 _ 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 /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kenuml <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 : _Sf�u6 5 -7-7 R13Y (,k <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE-#7-qs-t <br /> PROGRAM ELEMENT # 15�q CURRENT STATUS <br /> # OF UNITS EPA ID #: INSPECTION CODE <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 and that the work to be performed wilt be done <br /> in accordance with all applicable <br /> eSSAN JOAO22UIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE 4. y /2 <br /> Title: C/ // _ c1a,..L Date: <br /> AUTHORIZATION TO RELEASE IN MATION: In addition to the above, when applicable, I, 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 /> environmenta L/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 /> 3640 <br /> REHS l � / /� SUPV _/_/_ ACCT ,� L� UNIT CLK _/_/_ <br />