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�Jp <br /> GENERAL PROGRAM FILE New _ _ Change Edit /�► (PROG3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME / 1 )A rdoo S�el <br /> I RECORD ID # L) � ...{ PRIOR SWEEPS/CCMPV#ll 1760 7 60 L <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 u/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/Exert 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 L9 Generator _ Sm Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( -50 ) Transfer Ste _ 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 Hal Waste Haz Mat PPL _ <br /> Other Lead Agency Site _ Agency: RWOCB DTSC NPL Site RB/H2O Q Other <br /> SOLID WASTE: Landfill _ Transfer Ste _ Recycling Fac Waste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster _ No. Stationary Compactor Site <br /> t <br />' VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # G/j / PROGRAM ELEMENT # Zg. SQ 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 bitted 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 laws. <br /> APPLICANT'S SIGNATURE <br /> Title: 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 avaitabLe 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 /> RENS +_/_/ SUPV _/_/ ACCT UNIT CLK <br /> VV <br /> _/ /_ <br />