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GENERAL PROGRAM FILE New Clrr+nge Edit (PRDG3) revised 5/21/43 <br /> FACILITY ID M �(/I �] FACILITY NAME ^ <br /> RECORD ID 0 PRIOR SWEEPS/COMP R _- <br /> DAIRYs Grade A Grade a Milk DispetreerNumber of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Corrrrri-%eary ___ Mobile Food Produce Stand fee Plant <br /> seating Capacity Sq Ft Mnrket w/rnod rrep! Y / N <br /> Teoporary food Facility Special Food Event Vendlrrg Mnchines Nurrber of Yetding Unita <br /> Food Vehicle Make Lieence M Registratiori 0 Color <br /> HAZARDOUS WASTE: Tons Generated/Yr _ TIERED PERMIT Facility CA CE POR <br /> HOUSING: Hotel/Rotel No. of Llnits Jnil/Exempt Institution Housing Abatement <br /> Eaployee Housing No. of Employees Approx Dates of Occupancy / 1 to _-- <br /> T LIQUID WASTEt Pumper Vehicle Pumper Yard Chemical Tollets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator SM Generator <br /> Storage (2-10) Storage (11-SO) Storage ( >50 ) Transfer Ste � Ltd Hauler Yet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa 1 / Hunker of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ ASsess UST/CArLoc Haz Waste Haz Hat PPL <br /> Other Lead Agency Site Agency: RWOCB OTSC NPL Site RB/H2O Q Other <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fne Waste Storage Fac Ag waste/Exempt Site <br /> SW Vehicle No. Dmmpater No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kernel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 't ( ) < ) <br /> CONTACT 2 < <br /> DESIGNATED EMPLOYEE 0 �1.( PROGRAM ELEMENT 0 rf(i'S'�] CURRENT STATUS <br /> M OF UNITS : . EPA 10 9.- 6 INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the u r w itill.rf M'}' acknowledge that ell site and/or <br /> project specific PHS/EHD horncc5ha�pes associated with this facility or activity will be bitted to the party identified as the <br /> BILLING PARTY on this forms P y�ala0 certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAOUIN COUNTY Ordinance Codes and/or Standards and State andlor Federal taws. <br /> APPLICANT'S SIGNATURE : /CU <br /> Title- � i Rate: I`��` - fare 1011 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property;located at the above site eddress hereby authorize the release of any and alt results, geotechnical data and/or <br /> ernirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is 'available and at the amaze time It is provided to me or my representative. I'A1f.Q�7 0 <br /> Fee Amount Amount Paid Date of Payment Payment type Receipt 0 Check R Recvd By <br /> 23 5 L 3 <br /> RENS / C -- / SUPY / _�!__ ACCT Y 1/ / UNIT CLKl / <br />