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GENERAL PROGRAM FILE Change Edit (PROG3) revised 5/21/93 <br /> FACILITY 10 xFACILITY NAME f%/.�nG �G SrLP <br /> 1 <br /> RECORD ID 2 PRIOR SWEEPS/COMP It <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 B Registration I* Color <br /> H1l2AROCUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE POR <br /> HOUSING: Hotel/Motel No. of Units Jail/Exempt institution Honing Abatement <br /> Emptayee Housing No. of Employed Approx Dates of Occupancy to --1----J <br /> LtOUIO WASTE: Pumper Vehicle Pumper Yard Chemical Toitata No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing L9 Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) Storage ( >50 ) _ Transfer Sts _ Ltd Hauler ^ Vat Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Hunber of Pools Out of Service Poat Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Hal Waste Haz Mat PPL <br /> other Lead Agency Site Agency: RWC6 DTSC NPL Site RBl►120 O Other <br /> � L' ' <br /> /SOLID WASTE: LandfItl �7Transfer Sts <br /> Recycling foe Waste Storage Fac Ag Waste/Ext <br /> rSSiteSits <br /> SW Vehicle No. puofxtet No. _ Stationery Compactor <br /> VECTOR CONTROL: Poultry Faris Max Number of Birds Kemal <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> L vn Cr>r nyr., e��es G✓``l/kn. L�, SI(�6Zl� 3a 76 ( ) <br /> CONTACT 1 . <br /> CONTACT 2 : 'S C,>n S✓ �ti^n t ) '_______,-�_.._. l ) <br /> &&C4 t ave �'9 <br /> EUNtIS <br /> MPLOYEE * 7 � � EI�ME)1T /3(7 CilRRI:11T STATUS <br /> EPA IO !!: INSPECTION CODE : <br /> OILLING and COMPLIANCE AC10O&EDGEMENT: I. the undersigned owner, operator or agent of sane, aekrwwledge that all sift and/or <br /> project spectfle PHS/EHD hourly charges associated with this faeitity or activity will be billed to the pertY Identlfled as the <br /> BILLING PARTY on this fore. 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 JOAOUtN 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 saner, operator or amt of sww- Of <br /> the property located at the above site address hereby authorize the relesse of any and alt results, geotechnical dots and/or <br /> envirormentailsite assessment information to SAN JOAOUIN CDUNTY PUBLIC HEALTH SERVICES ENVIROMMOITAL HEALTH DIVISION as soon as <br /> It is available and at the ssme tieme it is provided to me or my representative. <br /> Fee Arrant Amount Paid Date of Paymment Payment Type Receipt ! Check ! Recvd OY <br /> REHS �I_J Si1DV �J_____/ A uiiiT+ cuc <br />