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GENERAL PROGRAM FILE New —AO— Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID it FACILITY NAME ICAL-W&STAF ROMDVAL �`T�?►� <br /> RECORD ID # PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade 3 Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Iee Ptant <br /> Seating Capacity Sq Ft Market Wood Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDCUS WASTE: Tons Genersted/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of Units Jsit/Exempt Institution Noosing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy _/ ! 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 Ste _ 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 /> / <br /> Ot'h'er Lead Agency Site Agency: RWQCS DTSC NPL Site RB/H20 Q Other <br /> _✓SOLID WASTE: Landfil Transfer Ste Recycling Foe Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpcter No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Foram Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY ani/or PROGRAM DAY 7/4 <br /> NIGHT <br /> CONTACT 1 : DAV 03 V�ACCfi Ff.Z A ( 02-0). 367 Q-2 <br /> 11 <br /> CONTACT 2 : ( ) ( ) <br /> DESIGNATED EMPLOYEE # J PROGRAM ELEMENT # G,43-DCURRENT 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 /> Titte: 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 representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Y� <br /> RENS / d_1 !3 SUPV / 2D / ACCT ,4 UNIT CLK _f_� <br />