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40 <br /> • PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME <br /> RECORD 1D # PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ FOOD: 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 Machines Number of Vending Units <br /> Food Vehicle Make License # L Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr 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 _J / to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toitets 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 Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/1120 Q Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle 3rNo. Dumpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> ERGENCY NOTIFICATION form this <br /> FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 : WnO (N)h- Y& - 21(0 M-L- vT <br /> CONTACT 2 : t�(\< {oi nc-a (2 A )63g - 2210 (20q ) 511- 17U- <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # 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 allLi le SAN JOAQUIN COUNTY Or a as and/or Standards and State arid/or Federal taws. <br /> (/ APPLICANT'S SIGNATURE <br /> Title 1�(Sfilcc �Ylana�r 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 /> 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 /> Check # Recvd By t # <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt -- <br /> REHS _/_ _/ SUPV _/ / ACCT UNIT CLK _/ / <br />