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GENERAL PROGRAM FILE New • Change Ed(t ✓ • (PROG3) revised 5/21/93 <br /> FACILITY 10 s Q �f FACILITY NAME ✓•Lf�� <br /> RECORD To 0 O Q _`, V CB PRIOR SWEEPS/COMP A <br /> DAIRY: Grade A Grade It Milk Dfspenser — Nurber of Containers in Multi-Head Unit <br /> _ F000: Restaurant _ Market _ Conmissery _ Nobi le Food _ Produce Stand — Ice Plant <br /> Seating Capee lty Sq Ft Market w/rood Prep: Y / N <br /> Temporary Food Facllity — Special Food Event _ Vending Machines __ Nunber of Vending Units <br /> Food Vehicle _ Make License M _ Regiseratimi s Color <br /> HAZARDOUS WASTE: Yons Generated/Yr TIERED PERMIT FecItIty : CA — CE _ POR — <br /> _ HOUSING: Hotel/Motel _ No. of Units Jail/Exeapt Institution Housing Absteax!nt <br /> Eoployee Housing _– No. of Eaployees Arprox Dates of Occupancy _/_/_ to <br /> LIQUID WASTE: Pauper Vehicle Pu:per Yard Chemteal Toilets No. <br /> Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care _ Acute Care _ Skilled Nursing — Lg Generator _ Sm Generator — <br /> storage (2.10) _ Storage (11-50) _ Storage ( 150 ) Yrensfer Stu _ Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa — HuA:ber of Pools Out of Service Pool _ Natural Bathing Piece — <br /> _ stTE MITIGATION, Env t ron A3aess UST/GP Loc Ilan Waste _ Haz Mat PPL _ <br /> Other Lead Agency Site J Ag� RWQCR� DISC NPL Site __ Rg/H2O 0 Other <br /> _ SOLID WASTE: Landfill Transfer Ste _ ReCyclinq Fac Waste Storage Fee — Ag Waste/Exeapt Site <br /> N Vehicle <br /> No. Durpster No. Stationary Compactor Site <br /> _ VECTOR CONTROL: Poultry Farm __ Max Harbor of Birds Kernel <br /> EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAM <br /> DAY NIGHT <br /> CONTACT i t <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE If PROGRAM ELEMENT A h4: OI CURRENT STATUS <br /> M Of UNITS EPA 10 11: O� V INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of sme, acknowledge that ell site and/or <br /> Project specific PHS/EHO hourly charges associated with this facility or activity will be bitted to the party tyId ntjf led beed wilt ast� <br /> BILLING PARTY on this fmm. I also certify that I hove prepared this application and that the work to be pef <br /> In accordance with all applicable SA JOjAAQUIN COUNTY Ordinance Codes end/or Standards and State end/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> ,,fres� <br /> / q Page 1011 <br /> Tftla::D r,e r ' lYIVIroy%M E 144M �f�p�,n'`�'�}(`7� �tg__ Date: / – 17 – 113 - <br /> AUTHORIZATION TO RELEASE INFORMATION. In addition to the above, when applicable, 1, the owner, operator or agent of arm. of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechniceL data and/or <br /> environnental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon ae <br /> it is available and at the sane time It 1s provided to me or my representative. <br /> Fee Anntatt Amunmn <br /> ot Paid Date of Payment Payt Type Receipt Al Check !ANIL <br /> Recvd By <br /> q: z <br /> RENS /�/ SUPV 7-1-1 ACCT UNIT LK <br />