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(e <br /> GENERAL PROGRAM FILE New Change t tPROICM revised 81/261" <br /> iFACILITY 10 # } FACIIlTY NAME tcJ .S7' - <br /> 2 <br /> RECORD ID # Q O—�C> PRIOR SWEEPS/CCMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Mutti-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 # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> HOUSING: Hotet/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 Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sts Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( "0 ) Transfer $to _ Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Poot/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: RWCC8 DTSC NPL Site RB/H20 g Other <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle ✓ No. Dunpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMFRGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 ( ) ( ) <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # 3 �� PROGRAM ELEMENT S CURRENT STATUS �`+ `v <br /> .s <br /> # OF UNITS EPA ID #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that sit site and/or <br /> project specific PHS/EHO 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 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, 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 sit results, geotechnical data anctfor <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 Psyisent Type Receipt / Check S Recvd By <br /> i <br /> REHSI/ /�f SUPV /� ACCT UNIT CLK �J__l <br />