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GENERAL PROGRAM FILE New Change Edit (PR0G3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR SWEEPS/CCMP # <br /> DAIRY: Grade A 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 w/Food Prep: Y / N <br /> Temporary Food Facility _ Special Food Event _ Vending Machines _ Nurber of Vending Units <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ PSR <br /> _ HOUSING: Hotel/Motel _ No. of Units Jail/Exempt Institution Housing Abatement <br /> Enployee Housing _ No. of Enployees 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 /> ��!! <br /> RECREATIONAL HEALTH: Pool/Spa _ Number of Pools Out of Service Pool _ Natural Bathing Place <br /> X SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste _ Hai Mat PPL _ <br /> Other Lead Agency Site __1Z Agency: RWOCB DTSC _ NPL Site _ RS/H20 Q _ Other _ <br /> _ SOLID WASTE: Landfill Transfer Ste _ Recycling Fac _ Waste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle No. Duipster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for <br /> /this FACILITY and/or PROGRAM '(/�q rJ/ DAY"���� NIGHTS �lS <br /> CONTACT 1 : In t4 ,,—lf /-�� &-ST/tiI / _ QL=n�s�� `r—�q�3 � <br /> CONTACT 2 : (7(IF7 f • of P—C, AS ( Iq)—&L- s"/V7L <_) <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> # OF UNITS : EPA ID #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, 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 will be done <br /> in accordance with all le SAN JOAQUIN NTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE <br /> Title: e D ll�C ` &A^ r_ Date: <br /> AUTHORIZATION TO hLEASE INFORMATION: In Aition to the above, when applicab , 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 /> envirormentaL/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 />