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GENERAL PROGRAM FILE : New Change Edit (PROGI) revised 8/26/93 <br /> FACILITY 10 # /� /a FACILITY NATE <br /> RECORD 10 # ���G 3 C PRIOR SWEEPS/CCMP # <br /> DAIRY: Grade A Grade B _ Milk Dispenser Number of Containers in Multf-Hemd Unit <br /> _ F000: 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 Nachfnes Number Of Vandir4 Unita <br /> Food Vehicle Make License # Registration # Cola' <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility - CA _ CE _ PINT <br /> _ HCUSING: 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 Mursing _ L9 Generator — Sm Generator �,.. <br /> Storage (2.10) _ Storage (11.80) _ Steraga ( 180 ) _ Transfer Ste _ Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spe _ Number of Pools Out of <br /> Service Pool _ Natural Bathing Place <br /> SITE MITIGATION: Environ Assess _ UST/CAP Loc Hai Waste !` Hai M—at PPL _ — <br /> Other Lead Agency Site Agency: RWQC8 DISC NPL Site RB/1120 Q _ Other <br /> _ SOLID WASTE: Landfill Transfer Sta _ Recycling Fac _ Waste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle No. Quipster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kennet <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY Q f� MIGHT <br /> CONTACT 1 <br /> CONTACT 2 �'/�L� A/'✓7Yl[fI. ( L)�/VI - L (—_) <br /> DESIGNATED # PROGRAM ELEMENT # 2(G.J 7 <br /> CURRENT STATUS <br /> EMPLOYEE <br /> # OF UNITS EPA 10 #: %.fir. G G&-7,1, *, L/`,/ INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sant, acknowledge that ell 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. I also certi I have prepared this application end that the work to be performed will be done <br /> in accordance with all appli�ble SAN JOA IN TY Ordi a Codes and/or Standards and State end/or Federal laws. <br /> APPLICANT'S SIGNATURE : - <br /> ��EA/�� � 47 95- <br /> 7 Date- <br /> Title: <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 /> SUPV _/—�— <br /> ACC 1 C� J_GJ S 11NIT ftK <br />