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d i 1 <br /> (PRO(, revised 5/2 <br /> FACILITY il? 9 FACILITY NAME <br /> RECORD EC D ID 0 PRIOR SWFErsnomp # <br /> DAIRY: Grads A Grade a Milk Dispenser— <br /> Ntsrber of Containers In Multi-Head Unit <br /> FOOD: Restaurant Market COMMiSSAFY Mobile rood Produce Stand Ice Plant <br /> Setting Capacity _ Sq Ft Mnr'ket W/rocd prep: Y / N <br /> Temporary Food Facility _ Special rood Event Vendliq finchines Number of Veivding Units <br /> Food Vehicle Make licence # Realstratiori 0 Color <br /> /-t-;l HAZARDOUS WASTE: , Tons Generated/Yr TIERED PERMIT racIlIty : CA CIE PPR <br /> ,t,24 HOUSING- Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing – No. of Employees Approx Dsteq of Occupancy _/_/_ to <br /> LIOUID WASTE: Pumper Vehicle _ Purger Yard Chnmlcat Toftetn No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care _ Acute Care Skilled Nursing _ Lg Generator Sm Generator <br /> Storage (2-10) Storage (11-50) Stornpe ( >50 Trntiqfer Stn — Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Poo(/Spa Nur+er of rnntg Out of Service Pool Natural Bathing Place <br /> 41-ISITE MITIGATION, Environ Assess 4--l'-UST/CAP Loc Haz Waste Naz Mat PPL <br /> Other Lead Agency Site Agency: RWOCR DISC NPL Site RB/H20 Q Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling rnc wnqtp storage rAc Ag Waste/Exempt Site <br /> SW Vehicle No. D(xtrKter 140. Stationary Compactor Site <br /> ,.aVr-CTOR CONTROL: Poultry Form MAX NL1obPr of 13frdq Ker"I <br /> EMERGENCY NOTIFICATION for this FACILITY arid/or PROGRAM DAY MIGHT <br /> CONTACT I il et c,,,q x, <br /> CONTACT 2 <br /> DEtIGNATED EMPLOYEE 0=D-2PROGRAM ELEMENT 0 CURRENT STATUS <br /> OF UNITS EPA ID 0: ✓ INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of Sam, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be bitted 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 arid/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title., 164 1J T Date:— ZAh 2 P(Ige 1011 <br /> AUTHORIZATION TO RELEASE INFORMATIA: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property loca:ad at *.se --hove 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 aveflable and at the same time It is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check 0 Recvd By <br /> ACCT UNIT CLK <br />