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ow <br />rFNFRAI PROGRAM FiLE New Change Edit _ <br />(PROG3) revised 5/21/93 <br />FACILITY iD N <br />All' 7 0 �: <br />FACILITY NAME <br />Receipt N <br />RECORD ID 0 <br />r7l <br />PRIOR SWEEPS/COMP M <br />DAiRY: Grade A Grade 8 Milk Dispenser <br />FOOD: Restaurant Market Comnissafy <br />Seating Capacity Sq Ft <br />Temporary Food Facility Special Food Event <br />Food Vehicle Make License b -- <br />HAZARDOUS WASTE: Tons Generated/Yr <br />_ HCUSING: Hotel/Motel No. of Units <br />Employee Housing No. of Employees <br />LIQUID WASTE: Pumper Vehicle Ptnper Yard <br />Humber of Containers In Multi -Head Unit <br />_ Mobile Food Produce Stand Ice Plant <br />Market w/Food Prep: ' Y / N <br />Vending Mnchlnes Number of Vending Units <br />Registratiofi 0 Color <br />TIERED PERMIT Fecility : CA CE PPR <br />ail/Exempt institution Housing Abatement <br />Approx Dates of Occupancy �/ / to <br />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 -SO) _ Storoge ( >50 ) ^_ Tronsfer Sta Ltd Hauler Vet Clinic _ <br />RECREATIONAL HEALTH: Pool/Spa Nurber of Pools Out of Service Pool Natural Bathing Place <br />SITE MITIGATION: Environ Assess V UST/CAP Lo Haz Haz Waste Haz Mat PPL <br />other Lead Agency Site Agency: RWOCR DiSC HPL Site R8/H2O 0 Other _ <br />_ SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br />SW Vehicle No. Dumpster No. Stationary Compactor Site <br />VECTOR CONTROL: Poultry Farm Max Nurtr_r of 81rds Kennel <br />EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM <br />DAT NIGHT <br />CONTACT 1': <br />CONTACT 2 : <br />DE�iGNATEO EMPLOYEE aY I q/ C-(� I PROGRAM ELEMENT f! I `� w) I CURRENT STATUS <br /># OF UNITS : <br />EPA 10 0, <br />INSPECTION CODE , .-J J <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 futility 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 />APPLiCANTOS SIGNATURE Page I of; <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 assestment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />_" .L_ ...... 9.1— it to nrnvided to me or my representative. <br />Fee Amount Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt N <br />Check 0 <br />Rec`� BY <br />(/ 77 <br />REHS I —I—/— I SUPV <br />ACCT �rJ- / • / UNiT CLK <br />