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GENERAL PROGRAM FILE : Neyi <br /> Change Edit <br /> `I —$ (PROG3) revised 5/21/93 <br /> FACILITY.ID / D0 I T]E]PR <br /> y'" (ACIL ITT NAME RECORD ID ! k �� IOR SNEEPS/CMP / <br /> _ DAIRYt Grads A __ Crede e _ Milk Dfapensser — Ntsr6er of Containers In Multi-Head Unit <br /> FOODS Restaurant __ Market Ca lssmfy Mobile Food <br /> Seating Capacity S it Produce Stand __ lee Plant _ <br /> G __ Market u/food Prep: Y / N <br /> Tmhicle Food Facility ty _— Speclnl Food Event Verrlir Machines <br /> Food Vehicle Make —'- g xurrber of Vend irg Unite <br /> -- License M , Reciatretimi M Color <br /> HAZARDOUS WASTE: ^ Toro Generated/Yr TIERED PERMIT ractlity : CA <br /> ,__ CE PBR _ <br /> _ HOUSING: Note(/Notal _ No. of Units Jnil/Ex <br /> Esptoyee Housinges O institution Housing Abatement <br /> __ No, o! Enployeee Approx Dates of Occupancy —/—/_ to <br /> _ LIQUID WASTES Purger Vehicle _— Pumper Yard Chemical Toilets No. <br /> — package ix Plant _ <br /> MEDICAL WASTES Prfinery Care _ Acute Care Skilled Nursing LU Generator <br /> Sm Storage (2-10) <br /> Storage (11-50) Storage ( >50 Generator <br /> — Transfer Ste __ Ltd Neul er __ Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa _ Nudwr of Pools Out of Service Pool _ Natural Bathing piece <br /> SITE M"I TION: Envfron AssessUST/CAr Lac Ilaz Waste _ Het Mat PPL _ <br /> OtHer Lead Agency Site _ e„ay: RWOCR , DISC — NPL Site _ RB/H20 Q _ other <br /> SOLID WASTE: Landfill Transfer Ste _R Recycling Fac _— Waste Storage Fee Ag Waste/Exempt Site _ <br /> SW Vehicle No. Dur"ter No, Ste[farory ospector C _ <br /> Site <br /> VECTOR CONTROL, Poultry farm _ Mnx Hurter of Birds Kernel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY <br /> '/ I NIGHT <br /> CONTACT i't <br /> CONTACT 222 <br /> DESIGNATED EMPLOYEE 1ij-I pROGRAH ELEMENT 0 1 SZ) CURRENT STATUS () <br /> I I <br /> K OF UNITSEPA 7 ID / - - - _- - _ - <br /> : INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site anal/or <br /> project @pacific PMS/EMD hourly chargee associated with this facility or activity will be billed to the party Identff ted as the <br /> BILLING PARTY on this form. 1 also certify that 1 have prepared this applieetfon and that the NQ 6e�er,formed will be done <br /> In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and Ste te�F' P <br /> �-it �f�rpt laws. <br /> APPLICANT'S SIGNATURE : <br /> mr IN <br /> Title: Date- Page 1011 <br /> the property'(oea tad at <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the oraser Ug� <br /> ep11 of saw, <br /> the above site of <br /> address hereby authorize the release of any end , geotechnfcal data end/or <br /> envfrormentst/alts assessment Informatfon to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ss soon as <br /> It Is available and at the ease, time it is provided to are or my representative. <br /> Fee Amount Amxnt Paid Date of Payment Payment 1 <br /> ype Receipt R Check M Recvd By <br /> � rC 1417 <br /> RENS 1/ / U SUPV ACCP IIrr <br /> /__/_. UNIT CLK <br />