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GENERAL PROGRAM FILE New - Change <br />Edit 1"'01 (PROG3) revised 5/21/93 <br />FACILITY <br />ID # <br />FACILITY NAME'l�l' <br />RECORD <br />ID # <br />PRIOR SWEEPS/COMP # <br />DAIRY: Grade A _ Grade B _ Milk Dispenser _ Number of Containers in Multi -Head Unit <br />FOOD: Restaurant _ Market _ Commissary <br />Seating Capacity Sq Ft <br />Temporary Food Facility _ Spec iaL Food Event <br />Food Vehicle Make License # <br />HAZARDOUS WASTE <br />Tons Generated/Yr <br />Mobile Food _ Produce Stand Ice Plant <br />Market w/Food Prep: Y / N <br />Vending Machines _ Number of Vending Units _ <br />Registration # Color <br />TIERED PERMIT Facility : CA _ CE _ PBR <br />HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br />Employee Housing _ No. of Employees Approx Dates of Occupancy _//_ to _/_J_ <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 Ste _ 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/H20 0 _ Other _ <br />SOLID WASTE: Landfill Transfer Sta _ Recycling Fac _ Waste Storage Fac _ Ag Waste/Exerrpt Site <br />SW Vehicle No. Durpster _ 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 <br />DESIGNATED EMPLOYEE # PROGRAM ELEMENT � CURRENT STATUS <br />� <br /># OF UNITS : EPA ID #: 0 P 1� `I�)�'-i1 <br />��, C^'' � INSPECTION CODE <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, 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. 1 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 />envirormental/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 />RENS _/_/_ SUPV _/_/_ ACCT _/_/_ UNIT CLK _/_/_ <br />