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1 <br /> GENERAL PROGRAM FILE New Change Edit }(PROG3) revised 8/26/43 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR SWEEPS/COMP a jj <br /> 1� <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 /> Beating capao i ty fiq rt _, MarkOt fA/Foiird Propi Y <br /> L <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/Ex"pt Institution Housing Abatement i <br /> Enployee Housing No. of Employees Approx Dates of Occupancy - �_/ to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Caro Acute Care skitled Nursing Lo Generatar Sm 4+nerstor <br /> Storage (2-10) _ Storage (11-50) _ Storage ( X50 ) Transfer Ste Ltd Hauler _ Vat Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of service Pool Natural Bathing Place , <br /> X SITE MITIGATION: Environ Assess UST/CAP X Loc Haz Waste Haz Mat PPL <br /> - _ other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 0 other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fees 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 for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 ( ) ( ) <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> i <br /> it OF UNITS : EPA ID #: INSPECTION CODE : <br /> i <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this for I also c tify that I have preps his application and that the work to be performed will be done <br /> in accordance with at appticabl S JOA UIN di C and/or Standards and State end/or Federal taws. <br /> APPLICANT'S SIGNAT RE : <br /> a is <br /> Title: went Contractor Dater 1/5/94 <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 all results, geotechnical data and/or <br /> envirornental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is av,nilable 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 / / SUPV /_J ACCT —��_f UNIT CLK <br />