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GENERAL PROGRAM FILE New Change Edit _ (PROG3) revised 5/21/93 <br /> FACILITY 10 s 40 FACILITY NAME (✓ j �I/,•t L;)1 <br /> 0.ECOt0 10 0 CJ PRIOR SUEEPS/CCMP 0 <br /> DAIRY Grade A _ Grade B Milk Dispenser _ Ntnber of Containers in Muhl Head Unit <br /> _ FOOD: Restaurant _ Market _ Caatalssary, — Noblie food _ Produce StA d — Ice Plant — <br /> Senting Capacity 54 Ft Market w/Food Prep: T / N <br /> Teamcary Food Facility _ Special Food Event _ vending Machines _ Ntarber of Vending Units <br /> food Vehicle _ Make License / Registration 1 Color <br /> I <br /> HAZARDOJS WASTE: Tons Genereted/Tr TIERED PERMIT Facility : CA __ CE -_ PBR _ <br /> _ HOUSING: Hotel/Hotel _ Na. of Units Jall/Exeapt Institution Housing AbateTMnt _ <br /> Eaplayee Houaing _ No. of Eaptoyees Approx Dates of OcCuPmvy _/_�_- to <br /> LIQUID WASTE:WASTE: Punper Vehicle Punpor Yard _ Cleaical Toilets — No. Package Tx Ptant <br /> _ MEDICAL WASTE: Primary Care Acute Care _ Skilled Nursing _ Ll r neretor _ 9a Generator — <br /> Storage (2-10) _ Storage (11-50) __ Storage ( 150 ) __ Transfer Ste _ Ltd Houler __ Vat Clinic _ <br /> i_/RECREATIONAL HEALTH! Pool/Spa — Number of Pools Out of Service Pool — Natural Bathing Piece <br /> "' SITE MITIGATION: Environ Assess UST/CAP Lac Hat Waste — Het Not PPL _ <br /> Other lead Agency Site _ Agency: RUOCB DTSC __ NFL Site __ RB/1:20 Q __ Other — <br /> _ SOLID WASTE: Landfill Transfer Sts — Recycling Fse — Waste Storage Fac Av Waste/Extart Site <br /> SW Vehicle _ No. OL"ter — No. Stationery Compactor Site — <br /> VECTOR CONTROL: Poultry fare— Max Number of Birds Rennet <br /> . E14ERGENCT NOTIFIOATION for Uls FACILITY and/«' PROdtAM DAT NIGHT <br /> CONTACT 1 <br /> KI KVc�lu S LA f,mI4AP' 22 So C, ( ) (Sio )` . 6-7 <br /> CONTACT 2 ('f��N o4 I� 1 T- <br /> DESIGNAIED EMPLOYEE ! nC� '� PROCRAFI9 ELENE)Iit �-�p,�/�� d)RRENT STATUS <br /> I OF UNITS : EPA 10 0- CAD x(J S t;9� 19q INSPECTION CODE <br /> BILLING and COKPll ANCE AC)OiOWLEDCEMENT: 1, the undersigned owner, operator or Want of same, ackzwwtadge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or metivlty will be billed to the party Identiftd as the <br /> BILLING PARTY on this farm. 1 also certify that I have prepered this application and that the work to be perfarard will be don <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordl �rud/or Standards and State and/or Federal laws. <br /> '.� APPLICANT'S SIGNATURE : �1 f u <br /> v Titte: Date: `?J / <br /> AUTHORIZATION TO RELEASE INFORIWTION: In addition to the above, when applicable, fe the owner, operator or agent of sea, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> emir«oeencal/aft• assnsaent Infornation to SAN JOAOIIIM QADITT PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION x sods as <br /> It is available and at the same time It to provided to am, or my representative. <br /> FFee Ae—t Arran(t�Paid Date of Payment Psyme nt/Type Receipt ! Check 0 Recvd By <br />