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GENERAL PROGRAM FILE New y Change Edit _ (PROO) revised 5/21M <br /> FACILITY ID ! 5Dr FACILITY NAME <br /> RECORD ID S �O D(o PRIOR SWEEPS/CC14P 0 <br /> DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Multi-Had Unit <br /> ►/ FOOD: Restaurant Market Commissary Mobile Food Produce Stand tee Plant <br /> Seating Capacity Sq Ft Njckat w/Food Prep: Y / N <br /> Torporary Food Facility Special Food Event ✓ Vending machines Mutber of Vending Units <br /> Food Vehicle Make License 0 Registration 0 Color <br /> HAZAROCUS WASTE: Tons Generated/Yr 1 TIERED PERMIT Facility : CA Cie PBR <br /> _ HOUSING: Notel/Motel No. of Units Jail/Exempt Institution wing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy to <br /> LICUIO WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Cue 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: Enviran Assess UST/CAP Lac Hai Waste Ha= Mat PPL <br /> Other Lead Agency Site Agency: RWoCB DTSC MPL Site RB/H20 a Other <br /> _ SOLID WASTE: Landfill Transfer Sta Recycling Fee Waste Storage Foe Ag Waste/Exempt Site <br /> SW Vehicle No. Dugxter Ma. ___ Stationary Compactor Sits <br /> VECTOR CONTROL: Poultry Fare Max Number of Birds Kant <br /> EMERGENCY NOTIF <br /> I <br /> CATION for this <br /> FACILITY and/or PROGRAM �JDAY NIGHT <br /> CONTACT 1 !� rdlo�rl'G�.�r—� ` j ( ) <br /> CONTACT 2 V <br /> DESIGNATED EMPLOYEE ! �f PROGRAM <br /> ELEMEli7 CURRENT STATUS <br /> N OF UNITS EPA ID M: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: t, the undersigned owrw:r, operator or agent of saes, acknowledge that all site and/or <br /> project specific PRS/EHO hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this fore. I also certify that I have prepered this application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAOUIN COLIM Ordinance Codas ad/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Data: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I„ the owner, operator or agent of sacs, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotachnical data and/or <br /> environmental/site assessment inforestian to SAM J"MIN Mum" PUBLIC HEALTH SERVICES ENV'ROMENTAL HEALTN DIVISION as soon as <br /> it is available and at the same time it is provided to me or mry representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt t Check 0 Rscvd BY <br /> UNIT CL1C <br /> REHS _��/ �I_�/ A <br />