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t <br /> GENERAL PROGRAM FILE New Change Edit (PROC3) revised 5/21/93 <br /> FACILITY ID # � ?2 7 FACILITY NAME <br /> RECORD ID # SJJ / C'Y PRIOR SWEEPS/COMP # <br /> _ DAIRY: Grade A [_ Grade B _ Milk Dispenser _ Number of Containers in Multi-Head Unit <br /> 4FOOD: Restaurant 0 Market Commissary _ Mobile Food _ Produce Stand _ Ice Plant <br /> Seating Capacity Scl Ft Z;L%iL Market w/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/Exempt Institution Housing Abatement _ <br /> Employee Housing _ No. of Employees Approx Dates of Occupancy _J /_ 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 /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool _ Natural Bathing Place <br /> ' / i <br /> SITE MITIGATION: Environ Assess ✓_ UST/CAP Loc Haz Waste _ Haz Mat PPL <br /> Other Lead Agency Site _ Agency: RWOC8 DTSC _ NPL Site _ RB/1120 0 _ Other <br /> _ SOLID WASTE: Landfill Transfer Sta _ Recycling Fac Waste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle _ No. Dumpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kennel _ <br /> EMERGENCY NOTIFICATION <br /> fforr'L this FACILITY and/or PROGRAM �{/� DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 : j I A Cf— O —�L • �-`�''` (—) <br /> DESIGNATED EMPLOYEE # C` U 1 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 applicable SAN JOAQUIN COUNTY/O�rdinnance)Codes and/or Standards and State and/or FederaL laws. <br /> APPLICANT'S SIGNATURE �: �'/.�7u'�1�,CJ,LH <br /> T i t l e:Aaa.��j IIIk '�'Y1('L'lYf Lro Deec Date: cZVjI .� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 # Check # Recvd By <br /> ACCT <br />