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GENERAL PROGRAM FiLE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID N FACILITY NAME <br /> RECORD 1D 0 PRIOR SWEEPS/COMP N <br /> DAiRYt Grade A Grade 8 Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOOs Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N <br /> rary Food Facility Special Food Event Vending Machines <br /> Vehicle Make License N ;,igegst� Nutter of Vending Units <br /> :Teapo <br /> w rettai N Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA. CE POR <br /> HOUSINGS Hotel/Motel No. of Units Jai(/Exempt institution Housing Abatement <br /> ErlplOyee Housing No. of Etrployees Approx Oates of Occupancy to <br /> 'LIQUID WASTEt Pumper Vehicle Purper Yard Chemical Tollets No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-SO) _ Storage ( >50 > transfer Ste Ltd Hauler Vet Clinic <br /> — RECREATIONAL HEALTH:' Pool/Spa Nurber of Pools Out of Service Pool Natural Bathing Place" <br /> SiTE MITIGATION: Environ Asses UST/CAP Loc Inez Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWOCB DiSC NPL Site RB/1120 0 Other <br /> _ SOLiD WASTEt,Landfitt Transfer Ste 0 Recycling FPC Waste Storage Fac Ag Waste/Exertpt Site'-' -' <br /> SW Vehicle No. Dun-Ater No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry farm Max Number of Birds Kernel <br /> EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAMNiGHT. <br /> CONTACT 1•t <br /> CONTACT 2 <br /> DE§IGHATEO EMPLOYEE • PROGRAM ELEMENT 0 CURRENT STATUS <br /> 9 OF UNITS : EPA iD N: 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 PMS/EHO hourly charges associated with this facility or activity wilt 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 applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal taws. <br /> APPLICANT'S S GNATURE <br /> Title: Date: Page 1011 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property'tocated at the abovs site address hereby authorize the release of any and all results, geotechnical data end/or <br /> environmental/aIto atsestment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROiMENTAL 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 N Check N Recvd By <br /> REHS ^/ / SUPV �/ /___ ACCT _/ / UNIT CLK �/ / <br />