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19-20-1993 11 45A(1 FR01" J1 l 15775742 P.04 <br /> i �LI�,— <br /> r,FNFRAL PROGRAM FILE : New / Change Edit _ (PROG3) revised 5/21/03 <br /> r 1 FACILITY NAME <br /> FACILITY ID # � ` 1 � <br /> RECORD ID 0 �� [� `)�' PRiM SWEFFS/COMP # <br /> DAiRY: Grade A Brad@ B Milk Dispenser Numtx>r of Containers in Multi-Haad Unit <br /> _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand ice Plant <br /> Seatirg Capacity Sq Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility Special rood Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # I Color <br /> HAZAROCUS WASTE: Tons Generated/Yr TIERED PERMIT Fneitity : CA CE PBR <br /> HOUSING: Note(/Motel No. of Units Jail/Exe.Mt institution Housing AUatemE+nt <br /> Employee Housing No. of Employees _ Approx Dates of occupancy �/ /_ to <br /> LICUID WASTE: Pumper Vehicle __ Pumper Yard Chemical Toilots No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acutt Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) Storage (11-50) Storage ( >50 ) Transfer Sta Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Poo(/Spa NtMr4r of Pools t vice Pool Natural Rathing Place <br /> :iX SITE MITIGATION. Envi Cori Assess UST/CAP Loc Haz _ H'at t i ' <br /> Other Lead Agency Site Agency: RWGCB �� DTSC __ i e RB/H2O D Other <br /> SOLID WASiE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> Sw Vehicle No_ Dumepster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Nur*.)er of girds Kennel <br /> EMERnFNCY NOTIFICATIO4 for this FACILITY and/or PROGRAM DAY NiGHT <br /> CnNTACT 1 Doug 01i]_ ind - (209 ) 577 - 5721 c_20$ 524 7869 <br /> CONTACT 2 . Lupe Angel _ (209 ) 577 5721 (__2_0j) 575 9666 <br /> DESIGNATED EMPLOYEE # �/1 PROGRAM ELEMENT # ��� CURRENT STATUS <br /> Y CF UNITS EPA 10 #: <br /> INSPECTION CODE 3 t 5 5� <br /> AILLiNG and COMPLIANCE ACKNOWLEDUMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> pro;act specific PHS/EHD hourly charges associated With this facility er activity will he billed to the party identified as the <br /> 7 <br /> RILLi4G 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 appli£a a SAN JOAOUiN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Date: ( rl ) - <br /> A'JTeORIZATION Jd 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 R w:eipt k Check # Rccvd Ay <br /> SUPV / _ J ACCT - - /- --/ UNiT CLK <br />