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t <br /> 5 GENERAL PROGRAM FILE New �J/ Change Edit (PROG3) revised 8/26/93 <br /> E <br /> EID # � / FACILITY NAME <br /> 7�? YJ PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ FOOD: Restaurant Market Commissary 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 _f / 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 UST/CAP Loc Hat waste Hax Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 0 Other <br /> SOLID WASTE: Landfitt Transfer Sta Recycling Fac haste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor Site <br /> pAYMENT <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY 0 4 NIGHT <br /> SAN JOAQUIN CO pkv C � <br /> TY <br /> CONTACT 1 < CA..ItL 1Q� <br /> CONTACT 2 . { 'At 61:A11�1 <br /> i; <br /> DESIGNATED EMPLOYEE # rY, PROGRAM ELEMENT # CURRENT STATUS <br /> # OF 4HtT5`: _ . —EPA-ID INSPECT.ION CODE. J�Q <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, 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 certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all applicable S N JOAQUIN COUNTY COrd�inance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Titte: /_ 1 Date: 1 <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 /> 77 <br /> y <br /> RENS _/ /RENS _/ / SUPV��/ACCTf UNIT CLX �,/T __ J_ <br /> RENS UNIT CLX /� __ / <br />