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Change Edit (PROG3) revised 5/21/93 <br /> A RAL PROGRAM FILE t New <br /> FACILITY ID / �£/ 7S a FACILITY NAME -- <br /> Co J SDG 7�0 <br /> { ` PRIOR SWEErS/COMP / - <br /> �RECdID IDS _— <br /> J <br /> �IDAIRYt Grade A _— Grade B —_ Milk Dlapenser _,_ Nuttier of Containers In Multi-Need Unit <br /> Commlessry _ "Ohl le food _ Produce Stand Ice Plant <br /> f00De Restaurant MarketNnrket w/Foorf rrep: Y / N <br /> Sestirg Capacity Sq Ft <br /> I Xurber o! Vending units <br /> Teiporery Food facility __ Special Food Event Verding Machines __ Color <br /> Lleense M __ Repletret tori a <br /> - Food Vehicle __ Make <br /> TIERED PERMIT rmcility ! CA CE __ POR <br /> I HAZARDOUS WASTE: •� Tons Gmere[ed/Tr I <br /> IL _ 'I HOUSING: Notal/Notal No. of Units J+il/Exempt Institution Housing Abetment <br /> No. of E t ees Approx Dates of Occupancy to <br /> i� Enployes Housing ap W <br /> i <br /> ` <br /> hemicel Toilets Ra, Package Tx Plant <br /> _!I LIOUID WASTEI P+nper Vehicle _ Pu,"r Yard f —' <br /> .V MEDICAL WASTE: Primary Care _ Acute Care ''_ <br /> Ski lied Nursing Lit Generator Sm Generator _ <br /> Neuter Yat Clinic <br /> Storage (2.10) _, Storage (11-SO) __ Storage ( >50 ) Traufer Ste __ Ltd <br /> RECREATIONAL HEALTH: Pool/Spa _ Nufier of Pools Out of Service Pool _ Natural Bathing Place <br /> i `X/ <br /> d SITE MITIGATION! Environ Assess X— UST/CAP Loc Net Waste Nei Net PPL <br /> { Other Lead Agency Site __ Agency- RWOCR_ DISC NPL site ` RB/H2O G Other <br /> !{ SOLID NASTEt land/ill Transfer Ste Recycling Fne Waste Storage Fec __ Ag Waste/Exenpt Site <br /> SW Vehicle _ No. Dunpater _ NO. <br /> Staff onary Compactor Site <br /> it fVECTOR CONTROL! Poultry ►arm _ Man Nudrr.of Birds Kennel <br /> EMIERGENCT NOTIFICATION for this FACILITY and/or PROGRAM <br /> DAT arum <br /> kCONTACT 2 ! <br /> jIDESIGNAIED EMPLOYEE R 7q7 <br /> ELEHENi / a(�SO CURRENT S7Aius <br /> Of UNITS f EPA ID S: INSPECTION CODE I ' <br /> t II <br /> 1 BILLING and COMPLIANCE ACKNOWLEDGEMENT 1, the undersigned owner, operator or event of seas, acknowledge that all alta end/or <br /> PrloJect specific PHS/EHD hourly charges associated with this facility or activity will M billed the err <br /> to e py Identified as the <br /> BILLING PARTY On this form. 1 also certify that I have prepared this application and that the work to be perforied will be done <br /> In accordance with sit applicable SAN JOAQUUUIII CUNTY rdinence codes and/or Standards and State and/or federal laws <br /> `PLICANTOO SIGNATURE 1, / t. <br /> Tltla! iOI� O�-a�'!S j Dote! (� -' J ✓ - >. <br /> i AUTHDRIZATION TO RELEASE INFORMATIONt In addition to the above, whm epplleable, I, the owner, apanta• or.pmt o► same,!o/ <br /> tM1a propertymloealed at the above all* address hereby Outhorhe the release of any and all results, geotechnlesl data and/or <br /> erivlro ental/alte sasessntat In to SAN JOAOUIN_COUNTY PUBLIC HEALTH,SERVICES ENVIRONMENTAL HEALTH DIVISION ea soon a1 ; i, <br /> the same time It Is provided to me or ail' representative. <br /> IE b available and at <br /> Re Amount Aaevtt Paid Date of Payment.; Pa meet Type Aaeolpt M C•.Check 0 i it By <br /> Ila <br /> e i7 <br /> ih 0237• ss43a3. G /e�.97 � � ';. 7F <br /> I <br /> PENS _/ _J_, SUPV _/._/ ACCT 97' . UNIiCLK <br /> • <br /> 16 F <br />