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GfNZRAL PROGRAM FILE Newr <br /> Chsnge Edit (PROG3) revised 5/18/43 <br /> F'AC:LITY 10 # FACILITY NAME <br /> RECORD IO # (� 5 YKIUK SWEEPS/G�P H <br /> _ DAIRY: Grade A �- Gracia B �- Milk Dispenser „ _ Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market COMI$sary _ Moblte Fw J _ Produce at" Ise plant <br /> Seating Capacity Sq ft Market Wood Prep: Y / N Nunber of Vending Machines <br /> Food vehicte �T Make _ License # „ Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/yr TIERED PERMIT Facility : CA CE PBR <br /> HOUSING: Hotel/Motet No. of units Jait/Exempt Institution <br /> Employe ang No. of Employees Approx Dates of Occupancy _/ / to <br /> LIQUID wASTE: Pumper Vehicle _ Pulper Yard Chemical Toilets No. Package Tx Plant <br /> _._ "_DSCA[ WASTE: Primary Care Acute Care Skilled Nursing �- LS Generator Sm Generator <br /> Storag, I? Storage (11-50) Storage ( >50 ) _ Transfer Sta Ltd Hauler Vet Clinic <br /> RECREATIO�A- POOL/Spa Number Of Pools Out of Service Pool Naturat Bathing Place <br /> MITIGATION: Environ Assess _ UST/CAP t/ Loc Naz Waste _ Haz Mat PPL <br /> �c r Lead 4;7.*icy Site Agency: RWQCB DISC NPL Site RB/H20 Q Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac AS W::_t^/Exempt Site <br /> sw Vehicte No. _ Dumpster No. Stationary Ca.;p&ctor Site <br /> HECTOR CONTROL: Poultry farm Max NLM4.V, of 81rds Kervwt <br /> EMt�:;L4C* ti'07tFICATION for this fACtLIiY anti/or P OGRAM DAY NICHT <br /> t31O )�$` - 3�b (1 o )�1 j 176-3 <br /> ._.•.A c r <br /> €SIGNAT£D EMPLOYEE # �C PROGRAM ELEMENT # a�� CURRENT STATUS <br /> # OF UNITSr^_ EPA 10 it: INSPECTION CODE <br /> q''LING ACKNOWLEDGEMENT. 1, the undersigned owner, opArator or agent of s we, acknowledge that all site and/or project specific <br /> �­;/EMD hourly charges associated with this facility or activity will be bitted to the party RaentiTiou as F.1- 51c�,mNo PARTY on <br /> s form. <br /> t also certify that I have prepared this application and thatthe work to be rformed wilt be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes nd Standards, State andel Feder aw5. <br /> AP?LICANT'S SIGNATURE _ <br /> Title: 4 ! — Date:____ <br /> AUTHORIZATION TO RELEASE FORMATION: in addition to the above, when apptioa le, 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 ell 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 avaiLabie and at the Namt: time it is provided to me or my reprpfrntAtive. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check R Recvd By <br /> ACCT <br /> to'� tT'_'.-L�hl?TI-T tJl IUO-AA tJJ T =t-0 1 • !� <br /> aR�r � <br />