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Change Edit (PROG3) revised 5121/93 <br /> GENERAL PROGRAM FILE New <br /> FACILITY ID # /�-, FACILITY NAME <br /> RECORD ID IN R� PRIOR SWEEPS/COMP IN <br /> DAIRY: Grade A Grade B Milk Dispenser Nurcher of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # I Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PER <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 Pumper Yard Chemical Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) Transfer Sta Ltd Hauler — Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> V/ SITE MITIGATION: Environ Assess UST/CAA Loc Hal haste Haz Mat PPL <br /> other Lead Agency Site Agency: RWQCB DISC NPL Site RE/1120 Q Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac 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 # 4 �— PROGRAM ELEMENT # aaS CURRENT STATUS <br /> IN OF UNITS : EPA ID #: 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 PHS/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 pre ared this application that the work to be performed will be done <br /> in accordance with all applicable SAN JOAQUIN Ordi nce Codes a / r rds and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE : Keith A . Tania . <br /> Title: Agent (Contract r) Date: 11/ 15/93 <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 /> envirormentaL/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Fee Amount Amount Paid Oate of Payment Payment Type Receipt # Check # Recvd By <br /> k <br /> [REHS / / SUPV ___�_/ / ACCT ��/ � � UNIT CLK /_f <br />