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. i <br /> GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/13/93 <br /> FACILITY 10 X FACILITY NAME <br /> RECORD ID k �`")��� �,� PRIOR SWEEPS/CLIP X <br /> DAIRY: Grade A Grade B _ Milk Dispenser _ Nurtber of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary _ Mobile Food _ Produce Stand _ Ice Plant <br /> Food Vehicte _ Make License d Registration @ Color <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N 0 of Vending Machines <br /> HOUSING: Hotel/Motel _ No. of Units Jail _ Employee Housing _ No, of Employees <br /> LIQUID WASTE: Pumper Vehicle _ Pumper Yard _ Chemical Toilets _ No. Package Tx Plant _ <br /> RECREATIONAL HEALTH: Pool/Spa _ Nuiber of Pools Out of Service Pool _ Natural Bathing Place <br /> 'VSITE MITIGATION: Environ ,As/sess UST/CAP _ Loc Haz Waste _ Haz Mat PPL _ <br /> Other Lead Agency Site 'X Agency: RW CB DISC _ NPL Site _ RB/H20 0 _ Other <br /> _ SOLID 'WASTE: Landfill _ Transfer Sta _ Recycling Fac _ Waste Storage Fac _ AS Waste/Exempt Site <br /> SW Vehicle _ No. Dumpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kernel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY <br /> CONTACT 1 : <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE J PROGRAM ELEMENT 9 C) I CURRENT STATUS <br /> EPA 10 Y: I J Approx Occupancy Dates _/_/_ to <br /> NUMBER OF UNITS INSPECTION CODE : <br /> BILLING ACKNCWLEOGEMENT: I, 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 prepared this application and that the wrk to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codas and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE : f—t�2 'Tn/I�.EP.CN/7E/.JT Ti2yc,L/N(� <br /> Title: F-Nr\1m oKllPLIAi.1C't-7- Date: <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 9 Check 7 Recvd By <br /> REHS _/�_ SUPV _/_!_ ACCT _/_/_ UNIT CLK <br />