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?1e 5,e ch&nie fmy­ �e a % 'SKi 1.Lt-�, NuKSINGr r-e,,iUT" ( <br />GENERAL PROGRAM FILE : New Change __X— Edit (PROG3) revised 5/21/93 <br />FACILITY ID # <br />FACILITY NAME <br />mer He i htS (20(\q- H05p i-EZZJ <br />5G- <br />RECORD ID # q 5co <br />PRIOR SWEEPS/COMP # <br />_ DAIRY: Grade A Grade 8 Milk Dispenser <br />_ FOOD: Restaurant Market Commissary <br />Seating Capacity Sq Ft <br />Temporary Food Facility Special Food Event <br />Food Vehicle Make License # <br />HAZARDOUS WASTE: Tons Generated/Yr <br />Number of Containers in Multi -Head Unit <br />Mobile Food Produce Stand Ice Plant <br />Market w/Food Prep: Y / N <br />Vending Machines Number of Vending Units <br />Registration # Color <br />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 Sta 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 Naz Waste Haz Mat PPL <br />Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 Q Other <br />_ SOLID WASTE: Landfill 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 # C( PROGRAM ELEMENT #�• 2� CURRENT STATUS <br /># OF UNITS EPA ID #: INSPECTION CODE <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 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, 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 />REHS / SUPV _/ j ACCT UNIT CLK _/ I <br />