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s <br /> ,ERAL PROGRAM FILE New Change Edit ! (PR OG3) revised 5/21/93 <br /> low <br /> ACILITY 10 S FACILITY NAMEt �[ ✓ V v <br /> e_. S <br /> RECORD ID B (�/�� PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B MItk Dispenser Number of Containers in Multi-Head Unit <br /> _ F000: Restaurant Market Commissary Mobite Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: T / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License t Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Tr a TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of Units Jolt/Exempt Institution Housing Abatement <br /> Eaployee Honing No. of Employed Approx Oates of Oazupency /�_/ to <br /> _ LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toitata No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lo Generator Sms Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage C s50 ) _ Transfer Sts Ltd Heiner Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Poots Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Hat Nat PPL <br /> ^ Other Lead Agency Sits Agency: RWCB DTSC NPL Site RB/H2O ai Other <br /> v/SOLID WASTE: Landfill Transfer Sto Recycling Fac Waste Storage Fac AS Waste/Exempt Sita ✓� <br /> SW Vehicle No. Dumpsta• No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Faro Max Number of Birds Kernat <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM 'DAY NIGHT <br /> CONTACT 1 . O f__ �) v Y, w �t a / ( ) Zen - Q 7 G <br /> CONTACT 2 : ( ) ( ) <br /> DESIGNATED EMPLOYEE B ✓ Z PROGRAM ELEMENT e,1 JYV6& CtRIRENT SiAM _ �e <br /> N OF UNITS EPA 10 2: tNSPECTION CODE : <br /> BILLING and COMPLIANCE AC7010WLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge, that all site and/or <br /> project specific PHS/EW hourly charges associated with this facility or%aetivity will be bitted to the party identified as the <br /> BILLING PARTY at this form. I also certify that I have prepared this applicati rk to be perforated wilt be done <br /> in accordance with all applicable SAAN.JOAOUtN COUNTY Ordinmrmcs Codes and/or St I or Federal laws. <br /> APPLICANT'S SIGNATURE s - J111 1-5 1994 <br /> Title: Date:_ - .,— <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, wimnr apRIW86 hl!4i�ig4rOfWr °f` °`f <br /> the property Located at the above site address hereby authorize the release of any and all rasutts, geotechnical data and/or <br /> environmentat/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES EVIROMMExTAL HEALTH DIVISION as SOCA as <br /> It is aveitabte and at the soma time it is provided to me or my representativ®. <br /> Fee Amount t Psi Data of Payment Payment Type Receipt t Check S Recvd By <br /> :7 Z/,s /_9 <br /> UNIT SUN /5� A f_LL1„J G CLK 54 <br />