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• BAN FiLE New Change f <br /> !' Edit (PROG3) revised 5/21/93 <br /> c�O� <br /> (o O��JJ <br /> FACILITY NAME <br /> RECORD ID 0 ��� Q q PRIOR SWEEPS/COMP N <br /> DAIRY: Grade A Grade a Milk Dispenser---- Number of Containers in Multi-Head Unit <br /> — FOOD: Restaurant Market CommissaryMobile food <br /> Snti Ca —'— Produce Stand lee Plant <br /> ng pacity Sq Ft _ Market w/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Machines <br /> Food Vehicle Number of Vending Unita <br /> Make Llcenae M Registrations N <br /> Color <br /> HAZARDOUS WASTE: Tons Generated/Yr <br /> _ TiERED PERMIT Facility CA CE POR <br /> HOUSING: Hotel/Motel No- of Units Jail/Ex <br /> empt Institution Housing Abatement <br /> Employee Housing No, of Employees Arprox Dates of Occupancy —/ / to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets <br /> No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing <br /> Storage (2-10) Storage (11-SO) _ Storage ( >50 ) Transfer Stag Generator Sym Generator <br /> — Ltd Hauler Vet Clinic _ <br /> __-_ RECREATIONAL HEALTH: Pool/Spa Hunger of Pools Out of Service Pool Natural Bathing Place <br /> _- SiTE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Hez Mat PPL <br /> Other Lead Agency Site Agency: RWOCR DiSC NPL Site RB/1120 0 Other <br /> — SOLiD WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY <br /> NIGHT <br /> CONTACT 1 't y 14- br jla,Y, :z\ <br /> CONTACT 2K 2n Y �'.-' l ( '/ ) 1 V <br /> DE§IGNATED EMPLOYEE 0 /�Y���1 1 PROGRAM ELEMENT 0 <br /> �- 1��y CURRENT STATUS <br /> * OF UNiTS EPA iD a!: <br /> INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of sacro, acknowledge <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party tIdentified all aft@ and/or <br /> s/ 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 SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> 1 Io <br /> APPLICANTnS SIGNATUREg! <br /> Title., ri, C- j�1cc fK/��' Date: 5, Page IOR <br /> AUTHORIZATION TO RELEASE iNFOR TiON: in addition to the above, when applicable, 1, 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 /> envirormental/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 Amoamt A Date of Payment Payment Type Receipt N Check +! <br /> RENS —/ / SUPV _/_ / — _I ACCT / Y / UNIT CLK / / <br />