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GENERAL PROGRAM FILE New v Change Edit (PROG3) revised 5/18/93 <br /> OACILITY ID # 2� FACILITY NAME Wm. C. Anderson <br /> RECORD ID # 3 ./O PRIOR SWEEPS/COMP # <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 w/Food Prep: Y / N Number of Vending.Machines <br /> Food Vehicle Make license # Registration # Color <br /> )7 <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA <br /> _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution �S <br /> Employee Housing No. of Employees Approx Dates of Occupancy <br /> _ LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. ---eroVPr ' �iE1r�Eat - <br /> PERMIT/SERVICESIt1 <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 /> L/ SITE MITIGATION: Environ Assess UST/CAP V---- Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 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 for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 Wm C. Anderson f ��1t 209 <br /> 931- 191 ( ) - <br /> CONTACT 2 <br /> ti 7 <br /> DESIGNATED EMPLOYEE # PROGRAM ELEME T # � CURRENT STATUS <br /> # OF UNITS EPA ID #: SV= INSPECTION CODE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END 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 prepar this application and that the rk to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance C s nd rds, to and rat ws. <br /> APPLICANT'S SIGNATURE <br /> Title• Date• <br /> AUTHORIZA• ON TO RELEASE INFORMATION: In addition to the above, when a l' able, I, the o er, 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 /> envirormental/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 /> 00 <br /> S 7 _72 L/,;2 Z/ <br /> RENS SUPV _/ / ACCT '�'1 ' `� UNIT CLK <br /> 'X <br />