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Change Edit • (PROG3) revised 5/21/93 <br /> GENERAL pROGRAM FILE New <br /> cacitlTY !D # FACILITY NAME <br /> RECORD ID # PRIOR SWEEPS/COMP <br /> DAIRY! Crede A Grade e T Milk Dispenser �._ <br /> Number of Containers in Multi-Head Unit <br /> _ <br /> FOOD; Restaurant Market Commissary _,_ <br /> Mobile Food Produce. Ice Plant <br /> Market w/Food Prep: <br /> Seating Capacity pe Ft Vending Machines N o '� g`Units <br /> Temporary Food facility _ Special Food Event t - I <br /> Hake License # Registraion <br /> Food Vehicle { <br /> `..� <br /> HAZARDOUS WASTE: TOns Generated/Tr <br /> TIERED PERMIT Facility CA CE PBR <br /> HOUSING: Hotel/Hotel _ No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing _ No. of Employees Approx Dates of Occupancy --J— <br /> uaulD WASTE: Pumper Vehicle __ puryer Yard __ Chemical Toilets <br /> No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care — Skilled Nursing Lg Generator _ Sm Generator <br /> Storage (2.10) Storage (i1.50) _ Storage ( X50 ) Transfer Ste — Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spe „_ Number of Pools _ Out of Service Pool — Natural Bathing Place _ <br /> S17E MITIGATION: Environ Assess ^ UST/CAP .1_._ LOC Hat Waste _ Hat Mat PPL T <br /> Other Lead Agency Site — Agency: RW0C6 DTSC _ NPL Site — RB/H20 0 _ Other <br /> _ SOLID WASTE: Landf 111 Transfer Ste _ Recycling fee _ Waste Storage Fee <br /> Stationary Caoste/Exepactor5itSite <br /> SW Vehicle _ No. Dumpster _ No. _,_, <br /> _ VECTOR CONTROL: Poultry farm _- Max Number of Birds <br /> Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM <br /> DAY NIGHT <br /> CONTACT 1 : (,�) <br /> CONTACT 2 : <br /> p-1 PROGRAM ELEMENT # Z Yom- l�D CURRENT STATUS <br /> DESIGNATED EMPLOYEE # C/ <br /> # #: INSPECTION CODE <br /> OF UNITS EPA ID <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT! I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific pHS/EHD hourly charges associated with this facility or activity will be billed to the port identified be done <br /> as the <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be pe <br /> rformed wtin accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and state andlor Federal laws. <br /> APPLICANT'S $IGN/ATURF - T - <br /> Title: !2/ 1:2Date! <br /> AUTHORIZATION TO RELEASE INFORMATION! In addition to the above, when appLio6ke, 1, life 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 end at the some time it is provided to me or my representative. <br /> Fee Amount Amount Paid Date 0f Payment Payment Type Receipt # Check # Recvd By <br /> ACCT UNIT CLK <br /> REHS PV [ / i v i <br /> Tririn e cr- <br />