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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY IDI % E <br /> "/ FACILITY NAME <br /> y`_RECORD IDI � �' PRIOR SWEEPS/COMP 0 <br /> DAIRY: Grade A Grade s Milk Dispenser _ Number of Containers in Multi-geed Unit <br /> FOOD: Restaurant Market _ commissary _ __ Mobile rood _ Produce Stand _ Ice Plant <br /> Seating Capacity Sq F[ Mnrket w/rod rrrp: Y / N <br /> Temporary Food roe fifty Special Food Event _ _ Vending Machines Number of Vending Units <br /> Food Vehicle Make LJcm<e N _ Regiatration I Color <br /> HAZARDOUS WASTE: ' Tons Generated/Yr _ TIERED PERMIT Facility : CA _ CE _ PBR _ <br /> _ HCUSING: Hotel/Motel _ No. of Units Jnil/Exempt Institution Housing Abatement _ <br /> Employee Housing _ No. of Employees ___ Approx Dotes of Occupancy _/_/_ to _.--J—J— <br /> LIQUID WASTE: Pumper Vehicle _ Pumper Ynrd _ Chrmirol 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) _ Stornge ( >50 ) Transfer Stir _ Ltd flouter _ Yet Clinic <br /> _ RECREATIONAL HEALTH: Pool/Spa NUrber of Pools Out of Service PTIlo1/oho( _ Natural Place <br /> _ SITE MITIGATION: Environ Assess UST/CAP _ Loc Haz Wnste ___ Hex I1FY�� WED <br /> O <br /> Other Lead Agency Site Agency: RWOCR Disc NPL Site -l131�b_ RB/H2O Q O r <br /> JAN 18 996 <br /> _ SOLID WASTE: Landfill Transfer Ste Recycling roc _ wnste Storage roc _ Ag mete/Exertpt Site <br /> sW Vehicle _ No. _ Dunrxter __ No. __ENVIF"NMFN?9bIy*+K&LT"e — <br /> PERMIT/SERVICES <br /> VECTOR CONTROL: Poultry Form _ Max Ntmtvr of Birds Kennet _ <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 t J �F_rvH ga !) — ( L - CJ ZO q (Zef) W 7 - el Z.3 3 <br /> CONTACT 2 : nSR�rw)lrvin 49 �)ZG9 (�) 479- D <br /> OEM GNATED EMPLOYEE I L1 q� PROGRAM ELEMENT I ,�q CURRENT STATUS <br /> I Of UNITS EPA ID I: INSPECTION CODE e <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 certif that I have prepared this application and that the work to be performed will be done <br /> In accordance with all mpg cab a SAN IN COON nce Codes and/or Standards and Stet, and/or Federal laws. <br /> APPLICANT'S SIGMA TURE - <br /> / 111,06 to fb Ixage 1011 <br /> Title: a= d '1 7 Date: <br /> AUTHORIZATION TO LEASE INFORMATION: In addition to the above, when spiSticable, 1, the owner, operator or agent of same, of <br /> the property located at the a)i,-:a site address herebnl authorize the release of any and all results, geotechnical date and/or <br /> environmental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the some time it Is provided to me or my representative. <br /> Fee Amc nt Amount Paid Date of Payment Payment Type Receipt I Check I Recvd By <br /> -xa3w. ����� �Ll6RENS _/__J__ SUPV _/__/_ __ ACCT �/ ��/ �' UNIT CLIC _/_/_ <br />