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GENERAL PROGRAM FILE New • Change Edit ✓ • (PROG3) revised 5/21/03 <br /> FACILITY iD A yL�� _— FACILITY NAME 1:2T <br /> V.l✓l.p ®� 5 -- <br /> RECORD ID A O 0 Z PRIOR SWEEPS/COMP A <br /> _ DAIRY: Grads A _ Grade B Milk Dimpe-ser _ Number of Containers in Multi-Heed Unit <br /> _ FOOD: Restaurant Market _ Con.ni ssnry ___ Mobile rood __ Produce Stand _ Ice Plant <br /> Seating Capecity Sq Ft Market w/rood Prep: Y / N <br /> Temporary Food Facility _ Specinl Food Event __ Vending Machines _ Nuiber of Vending Units <br /> Food Vehicle Make License A Registration A _ Color <br /> HAZARDOUS WASTE: , Tons Generated/Yr _ TIERED PERMiT rscility : CA _ CE _ PON <br /> HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing _ No. of Employees Approx Dates of Occupancy _/_/_ to ---- <br /> LIQUID WASTE: Pumper Vehicle _ Purper Yard Chemical loitets ^ No. _ Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing _ Lg Generator _ Sm Generator <br /> Storage (2-10) _ Storage (11-SO) _ Storage ( >50 ) Tronsfer Sto _ Ltd Hauler _ Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa _ Nurber of Pools Out of Service Pool _ Natural Bathing Place <br /> SITE MITIGATION: EnvironAA sass _z UST/CAP Loc Hat Waste _ Hat Mat PPL <br /> Other Lead Agency Site v' Agency: RWoM DISC _ NPL Site ^ RB/H20 0 _ Other _ <br /> _ SOLID WASTE: Landfill Transfer Stn __ Recycling ire _ Wnste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle No. Dunpater __ No. Stationary Compactor Site _ <br /> VECTOR CONTROL- Poultry Form _ Max Nudrr of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1't <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE A PROGRAM ELEMENT Av. O CURRENT STATUS <br /> A OF UNITS : EPA ID A: Y INSPECTION CODE : <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, 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 form. I also certify that I have prepared this application and that the work to be performed wilt be done <br /> In accordance with all applicable SA JOAOUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE A <br /> gf � �fr fake 1011 <br /> Tltte-V)'PQct r< �nVIrONVktell'iZLI' Qp_14 4fnLS Date- `l— l7 — 93 <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of some, 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/aite sssessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the sant time It is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt A Check A Recvd By <br /> REHS SUP,, ACCT / _ UNIT CLK _/ /_ <br />