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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # J 7�� FACILITY NAME <br /> RECORD ID # SdJ PRIOR SWEEPS/COMP # <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 /> Seating Capacity Sq Ft Market w/Food Prep: T / N <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/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy _J / to <br /> LIQUID WASTE: PuTper Vehicle Psper Yard Chemical Toftvtc- _ 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 C >50 ) _ Transfer Sta _ Ltd Hauler _ Vet Clinic <br /> _ RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ As UST/ Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB OTSC NPL Site RB/H20 0 Other <br /> _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac AS Waste/Exempt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor Site <br /> _ VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> LCONTACCT <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAMDAY NIGHT <br /> 1 : STEPHEN CHEN (209 ) 937 - 8827(209 ) 937 - 8829CONTAT 2 <br /> DESIGNATED MPLOYEE # L1 <br /> PROGRAM ELEMENT # Cq�t� j CURRENT STA <br /> ETUS <br /> INSPECTION CODE <br /> $ OF UNITS <br /> EPA ID #: <br /> -BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, 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 prepared this application and that the work to be performed will be done <br /> in accordance with all applicable 9KN J M COUNTY Ordi nce Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE : <br /> DEPUTY DIRECTOR P BLIC WORKS Date: OCTOBER 27, 1994 <br /> Title: the owner, operator or agent of same, of <br /> i THORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, <br /> authorize the release of any and all results, geotechnical data and/or <br /> the property located at the above site address hereby <br /> Y PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> environmental/site assessment information to SAN JOAQUIN COUNT <br /> it is available and at the same time it is provided to me or my representative. <br /> V- Receipt # Check # Recvd By <br /> Fee Amount <br /> 7��t Paid Date of Payment Payment Type P <br /> SUPV <br />