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GENERAL PROGRAM FILE New V Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR SWEEPS/COMP # Ji ,3 <br /> DAIRY: Grade A _ Grade B _ Milk Dispenser _ Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant _ Market _ Comaissary _ 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 # 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 _/_/_ 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 Ste _ Ltd Hauler _ Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool _ Natural Bathing Place <br /> _ SITE MITIGATION: Environ Assess v/UST/CAP Loc Haz Waste Haz Mat PPL _ <br /> Other Lead Agency Site _ Agency: RWQCB OTSC NPL Site _ RB/H20 Q _ Other <br /> SOLID WASTE: Landfill _ Transfer Ste _ 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 # / 3 'L PROGRAM ELEMENT # 2 9 S C7 CURRENT STATUS <br /> # 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/END hourly charges associated With this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. 1 also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date; <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 /> - environmental/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 Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS /r=/r-- / -V y/�–`/ ��'--' ACCT T/_/ / UNIT CLK _/_/_ <br />