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GENERAL PROGRAM FILE : New Change Edit (PROG3) revised 5/21/93 <br />FACILITY 10 # <br />2 Z 0 c <br />FACILITY NAME <br />T/ <br />RECORD ID At <br /># Z Z Z <br />PRIOR SWEEPS/COMP # <br />O <br />DAIRY: Grade A _ Grade 3 _ Milk Dispenser _ Number of Containers in Multi -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 _ Spec iaL Food Event _ Vending Machines —Number of Vending Units _ <br />Food Vehicle _ Make nLicense # Registration # Color <br />HAZARDOUS WASTE: Tons Generated/Yr < TIERED PERMIT Facility : CA _ CE _ PER <br />HOUSING: Hotel/Motel _ No. of Units Jail/Exempt Institution Housing Abatement <br />Employee Housing _ No. of Employees Approx Dates of Occupancy _//_ to _/ / <br />LIQUID WASTE: Pumper Vehicle _ Pumper Yard _ Chemical Toilets _ No. Package Tx Plant <br />MEDICAL WASTE: Primary Care _ Acute Care _ Skilled Nursing _ Lg Generator Sm Generator <br />Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) Transfer Sta 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 Haz Waste Haz Mat PPL _ <br />Other Lead Agency Site _ Agency: RWQCB DTSC NPL Site _ RB/H2O o _ Other <br />_ SOLID WASTE: Landfill _ Transfer Sta _ Recycling Fac Waste Storage Fac _ Ag Waste/Exempt Site <br />SW Vehicle No. Dumpster _ No. Stationary Compactor Site _ <br />VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kennel <br />EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br />CONTACT 1 <br />CONTACT 2 ( ) C ) <br />DESIGNATED <br />EMPLOYEE # <br />�. <br />i� <br />PROGRAM ELEMENT <br /># Z Z Z <br />CURRENT STATUS <br /># OF UNITS <br />EPA <br />ID #: t��D 6�d 9 ���% <br />I <br />INSPECTION CODE <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br />project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br />BILLING PARTY on this form. 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 JOAQUIN 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 owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br />environmentaL/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same time it is provided to me or my representative. <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />REHS %L / 2L/ C3 SU" _/_/_ ACCT _/_ /UNIT CLK _/_/ <br />