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',ENERAL. PROGRAM FILE New —$—/ <br /> _ Change Edit (PROG3) revised 8/26/03 <br /> FACILITY ID # D�/„ 677 <br /> FACILITY NAME � l D <br /> P,FCORD ID # /� 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 Prepi 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 /> MrDICAL WASTE: Primary Care Acute Care _— Skilled Nursing Lg Generator am Generator <br /> Storage (2-10) _ Storage (11-50) Storage ( >50 ) ' Transfer Ste _ Ltd Hauler _ Vet Clinic _ <br /> RFt;FtEATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: EnvironAss s UST/CAP v Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWGCB _ DTSC NPL Site RB/H20 0 Other <br /> cnllD WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Durpster No. Stationary Compactor Site <br /> VFCTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMFRGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 ( ) ( ) <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # V l-� PROGRAM ELEMENT # 70C) 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 /> proj-ct specific PHS/END 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 Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHnRIZATION 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 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 /> REHS i Iz / / SUPV _/ / ACCT '/ UNIT CLK _/_/ <br />