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GENERAL PROGRAM FILE New Change — Edit _ (PROGz3) revised 5/21/43 <br /> FACILITY ID I S-6 O FACILITY NAME <br /> RECORD ID D PRiOR SWEEPS/CLt1P -- <br /> DAIRY: Grade A Grade 3 Milk Dispenser Number of Containers in Multi-ileed Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand ice Plant <br /> Seatirx) Capacity Sq Ft Market w/Food Prep: Y / N <br /> Tnrporary Food Facility Special Food Event vending Machines Number of Vending Units <br /> Food Vehicle Make License 0 Registration 0 Color <br /> HAZARDOUS WASTE: Tons Generated/Yr I TIERED PERMIT Facility : CA CE PBR <br /> HOUSING: Hotel/Motel No. of Units jsil/Exempt Institution Housing Abatement <br /> Employee Honing No. of Employees ApproX Dates of Occupancy /_J to _/^- <br /> LIQUID WASTE: Purger Vehicle Ptmper Yard Chemical Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing -Agl�L,rTrnerotor 9a Generator <br /> Storage (2-10) Storage (11-50) Storage ( >50 ) Trensl�/s!SJ•� 'fd Ilsuler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out a ic9p,93 D Natural Bathing Place <br /> EN�PtjBGl�H4Q(///V <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Naz W '4 <br /> �a€P d//--"moi E ry--- <br /> Other Lead Agency Site Agency: RWOCB DTSC NPL"91 RV/ H2O 0 Ocher <br /> _ SOLID WASTE: Lardfill Transfer Sts Recycling Fac Waste Storage Fac AO Waste/Exempt Site <br /> SU vehicle No. Dumpeter No. Stationary Compactor Site <br /> 31j <br /> j VECTOR CONTROL: Poultry Fane Max ►umber of Blr•ds rennet <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 : e� r �'�' Z <br /> CONTACT <br /> �s�) -- / <br /> -- - (Y -7 PROGRAM ELEMENT /� CTlRRETit STATUS <br /> DESIGNATED E11PLOYE'e x <br /> 3 OF UNITS EPA 10 2: INSPECTION CC13E <br /> BILLING and COWLIANC£ ACKNOWLEDGEMENT: 1, the un&rslgrxd owner, operator or agent of same, acknmtedge that all site and/or <br /> project sprclfic PNS/E110 hourly charges associated with this facility or sctivity, will be billed to the party Identified as the <br /> BILLING PARTY on this fora_ I also certify that I have prepared this application and that the work to be perfore+.d will be donde <br /> in accordance with all applicable SAN 1OAQUIN COUNTY Ordl ioc Standards and State ad/or Federal laws. <br /> APPLICANT'S SIGHATUIR j� L <br /> Title! Date• - <br /> AU11roRIZATtON TO RELEASE INFORMATION:✓ in addition to the above, when applicable, I, the over, operator or agent of seem, of <br /> the proporty located at the above site address hereby authorize the rales** of any and all results, geot*chnical data and/or <br /> rrrvirormental/site ass"Wet information to SAN 10AculN COUNTY PUBLIC HEALTH SERVICES ENVIROWtEHTAL HEALTH DIVISION ata soon as <br /> it is available and at ttwr same time it is provided to me or my representative. <br /> Fee Amaint Amou,t-1'.a-id Date of Payment PayR►ent Type Receipt x Check ! By <br /> RENS SU" _J�J ACC ��� Lim 1T CLX L-f4 <br />