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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> s <br /> FACILITY 10 # /�, FACILITY NAME Yv► J L S � <br /> RECORD ID # �QJ PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ F000: 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 0 Cola' <br /> m <br /> HAZAROOUS WASTE: Tons Generated/Tr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotet/Motet No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy _J__J to <br /> LIoUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. ___ Package Tx Plant <br /> _MEDICAL WASTE: Primary Care Acute Care Skilled Nursing to 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 Hat Waste Max Mat PPL <br /> Other Lead Agency Site Agency: MaCa OTSC NPL Site RB/H2O 0 Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fee Waste Storage Fac Ap Waste/Exempt Site <br /> Dtampstar No. _ Stationary Compactor Site <br /> SW Vehicle No. <br /> F VECTOR CONTROL: Poultry Fam Max Number of Birds Kennat <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 C w / - )�•"•.+� --- l ) '"�— <br /> CONTACT 2 <br /> E- " MPLOYEE # G PROGRAM ELEMENT # 4/L/66T STATUS — < <br /> EPA tD #: INSPECTICK CODE <br /> BILLING and mXJMPLtANCE AC101WLEDGEMENT: I. the undersigned owner, operator or agent of samm, aeknowtedga that all site and/or <br /> project specific PHS/EMO hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY an this form. i also certify that I have prepared this appticstip INVANE"IbrIt to be performed wit be done <br /> in accordance with att applicable SAN JOAGUtN COUNTY Ordirw+ce Codes and/or St .A or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Oat*-. <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when sp�dfia�8( 1l ,Ntll_iM+FMt7h4iP1N0�IS401de' int of mase, of <br /> the property located at the above site address hereby authorize the retesse of any and att results, geotaehnieal data and/or, <br /> environmental/site assessment informmation to SAN JOACJtM COUNTY PUBLIC HEALTN SERVICES ENVIRO MENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Fee AmountA06WIt Psi' Date of Payment Peyma+t Type Receipt #' Check # Racvd By <br /> Jig. (50 <br /> A UNIT CLX <br />