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(FNERAL PROGRAM FILE New _ Change Edit (PROG3) revised 8/26/03 <br /> FACILITY ID # FACILITY f AAME <br /> ;a <br /> RF CORD IO # �� Q c�/ / PRIOR SWI EEPS/COMP <br /> d <br /> �- DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit r' <br /> FOOD: Restaurant Market Commisse y Mobile Food Produce Stand Ice Plant <br /> Seating Capacity _ 1q,gq rt Market w/rood Prep: Y / N <br /> Temporary Food Facility Special Food vent Vending Machines Number of Vending Units <br /> Food Vehicle Make Licens e # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of ' its Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employee Approx Dates of Occupancy i to <br /> LIQUID WASTE: Pumper Vehicle ?umper Yard Chemical Toilets No. Package Tx Plant <br /> MEDICAL WA SUs Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10)` St or qe x(11-50) _ Storage ( >50 ) Transfer Sta , Ltd Hauler _ Vet Clinic <br /> ^- RECREATIONAL HEAk• Pool/Spa Number of PaolaOut of Service Pool Natural Bathing Place <br /> _ SITE MITIV 0!ON: Environ Assess UST/CAP LOC Nat Waste Haz Mat PPL <br /> Otter Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H2O Q Other <br /> SO' ID WASTE: Landfitt Transfer Sta 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 NIGHT <br />{ CONTACT 1 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # D PROGRAM ELEMENT # ,T�� CURRENT STATUS .1 ^ <br /> # OF UNITS : EPA ID #: $ t � —+ 7" INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, 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 bitted to the party identified as the <br /> SILLiNG PARTY on this form. I also certify that I have prepared this application and that the work to be performed wilt be done <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <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 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 representativit. f-t— 0o5,3a '7 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ERF _/ / SUPV /_� ACCT UNIT CLK _/ I <br /> % Teem <br />