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GENERAL PROGRAM FiLE t New Change Edit (PROG3) revised 5/21/93 <br /> asc�Q FACILITY ID FACILITY NAME �1 ` 5i vim/c0U (O f <br /> C_ �s� <br /> RECORD ID / } 2 <br /> PRIOR SWEEPS/COMP M _ <br /> DAIRY: Grade A Grade a Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Sooting 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 N _ Registratiai N Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TiERED PERMIT recility CA CE POR <br /> HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy _J / to _J / <br /> LIQUID WASTEt Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> MEDICAL WASTE., Primary Care Acute Cire Skilled Nursing Lg Generator Sm Generator' <br /> Stora9e (2-10) Storage (11-50) _ Storage ( >50 ) Transfer Sta Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Poo(/Spa Nui>er of Pools Out of Service Pool Natural Bathing Place <br /> t/ SITE•MITiGATIONt Environ Assess UST/CAP 11(KLoc Ilaz Waste 1/ Haz Met PPL <br /> Other Lead Agency Site Agency: RWOCR DTSC NPL Site R13/1120 0 Other <br /> _ SOLiD WASTEt Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dun*A ter No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Nurttr_r of Birds Kennel 'F <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 (707-) 37'/. C y7 <br /> CONTACT 2 ( ) <br /> DE§IGNATED EMPLOYEE 9 ' PROGRAM ELEMENT N �1 �C5.) CURRENT STATUS <br /> 0 OF UNITS s EPA ID B: T 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 an this form. I also certify that I hay per ed this application and that the work to be performed will be done <br /> In accordance with sit appii ble SAN JOAQUiN COUNT Ordi Ince Codes and or Standards and State and/or Federal laws. <br /> APPLICANTrS SIGNATURE <br /> VJ.�. Date: Page 1013 <br /> Title: ss boslant w�. <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 sbove 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 Ii 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 d Check N Recvd By <br /> SUPV'' _/_ / ACCT / /_,_ UNIT <br />