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NI. -.HMu Lr i". Ub / r', 4 <br /> San Joaquin County-Environmental Health Dap„ ent <br /> HflzCIt00 Avenue-Stockton CA 95205-Phone: 209469-3420 PAyjW <br /> ejvr <br /> F?EF(,r:lvj <br /> APPLICATioN N 0 ZG15 <br /> ENVIttONDIENTAL,HP,ALTII <br /> PERMIT TO OPERATE SAN�OggU1N CO EMPLOYEE HOUSIrur OR LABOR CAMP ENVInOME T UN7}r <br /> ❑New Camp ❑CondillonA)Permit ❑ blulllple]'eery(L'crmancm IIouaing Camps onl• H1FgLTl1 C)FpgR AL <br /> ❑Amended Permll; ''Change ol'Operptur •ChAu yI Ann nl Permit for Cnlp,dar 1'e���N�`'/ — <br /> "ChangeofOpernlorAddrem 'Change ofOtraerAddre" d <br /> 'additional Finployeey Permit ID H: <br /> 0005643 <br /> �Et <br /> 1D 39-0321-EH <br /> Please Nora on C wrections or Changes in Fewility/Operaror Jrj/orination direetly on this form• D ti; 39000321 <br /> Site Name: A SAMBADO&SON 39-321 <br /> Location: 14000 E EIGHT Mill;RD,LINDEN <br /> Operator: A SAMBAbO&SON INC <br /> Nlalling Address: 8077 N TULLY RD,LINDEN CA 95230 <br /> Facility Phone q;(209)931-2568 <br /> Legal Olvncr-, SAMBADO,LAWRENCE J&BEVERLY <br /> New Orrner 7 Q OwncrAddress: 8077 N TULLY RD,LINDEN CA 95236 Yes No <br /> CornmvinflyfjW11fies Pr Owner Phone N:(209 931-2568 <br /> Comp- Cmnmunity Kitchen 9 � Yes No Q• <br /> Men: NumberorToilcts <br /> Women; Number ofToilcls Number ofSlaowors Number of-Lavatorics <br /> Number of Showers Number of Lavatories <br /> Huuslne Acrmm�tndafloug to hn ttrilized thla 1'eAr <br /> Bullditl� Ir.111pI0VClS <br /> Dormitories <br /> SF Dwellings from /OI/ (5 to lot/_31 j 15 Crop <br /> Apartments from map <br /> 01411er Oaa•ned MR/RV <br /> Otrncr Owned RR C,us — ' ^, Total Nu,nbcr of Days to be used This Calendar Year: <br /> NIH/RV Spaces Total Days Occupied by 25 or more Employees: v <br /> TOTALS Comps occupied by 25 or more Eml�lo'ers for 60 or more days in A year <br /> ❑Inactive Require a PUBLIC WATER SYSTEM Permit <br /> IL la°l: In order to protect your land use status,if camp"A not be used this year but is intended <br /> , <br /> for use in the future,Check this Box pad return this appljcatioa <br /> Feo Schedule <br /> l'erntanent Camp Annual Permit re( S35.00+ i - - - I" <br /> Number of Employers 1 G Qa S12.00each-S fr�C� <br /> ❑ Orchard Camp 1 cmait I'ce <br /> Number of Employers $95,p0=$ <br /> ❑ Transfer oPO�rTaship <br /> ❑ Pemaanenl Amendmcnt Fec S20.00+ NumtxrofAdditional Employees $20.00=S <br /> (] Late Application Pec $70.00 t (a$12-00 eech—S <br /> Number of Cmployees Q S24.00 each— <br /> Pee must be submilted with Application /�11 <br /> Remit TOTAL FEE as CALCULATED ABOVE In the ENCLOSED SrU-ndressedtEn elope E l <br /> DUS <br /> MAKE CHECKS PAYABLE to E110 <br /> Applicant agrees to allec necesgrdmicAr) inspections Incident to iysaanee of a rE1Rh1IT TO OPERATE. Applicant Agrees th"I this project(CAMP)shall be ape,atcU <br /> and gfeo, ode In Chapter <br /> 1 aiub the applicable prorlslous of the EDII'LOVEE HOUSING ACT,Chapter 1,Part 1,Dlvisior, 13 of the California Health <br /> rnidSq/e0•Corte and Cltaplcr I,Subchapter 3,Tltte 25,Callfornia Code of ftillatians. <br /> Applicant Name L ,CF <br /> (Phase PRINTorrl'PE) a wR q��oa�� Title <br /> �'n EN�� ❑Partnership <br /> Address r7 'r LC Corporalion <br /> Applicant Signature D R `�3� Phone 93 Lq <br /> _ <br /> Amount Paid Dale of Paynrenl DAte of Application '' <br /> Payment t Type y yP Check/RoeeiplN Received B <br /> y AccountlD <br /> l / Lt%3yD 0003775 <br /> Faellity,ID Program Record 11) <br /> FA00041 i3 PR0270321 P� Asslgnerl tO PWs to <br /> 2765 2424-VELOSO <br /> WA0515>47 <br /> Report aY:706$ � <br />