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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # /h rl?,S/ FACILITY NAME <br /> RECORD ID # 50,5✓��l/7 PRIOR SWEEPS/CCMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Mutti-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: 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 to <br /> to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <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 /> —ZSITE MITIGATION: Environ Assess v UST/CAP Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 Q 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 <br /> OTIFICATION for this FACILITY and/or PROGRAM DAY <br /> AY MIGHT <br /> CONTACT 1 ICanN rAthC �7)'75q - 201) -7SY- 1 <br /> 07 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # � PROGRAM ELEMENT it S r7 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 att site and/or <br /> project Specific PHS/EHD 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 /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and At 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 /> !p 6 y `'a 3 z1 I q1 24y <br /> UNIT CLK <br /> RENS /�C� / SUP �/� / ACCT /_„�/ <br />