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.c- <br />Lo <br />GENERAL PROGRAM FILE NeW _ _ Change Edit (PROG3) revised 81261" <br />FACILITY ID # <br />� 0 �\ <br />FACILITY NAME <br />% �yf �., /� 7 <br />RFCORD ID # <br />/� D / <br />PRIOR SWEEPS/COMP # <br />No. <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 Special Food Event <br />F,,rd Vehicle Make License # _ <br />HAZARDOUS WASTE: Tons Generated/Yr <br />HO(ISING: Hotel/Motel No. of Units <br />Employee Housing No. of Employees <br />110111D WASTE: Pumper Vehicle Pumper Yard <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 s CA CE PBR <br />Jail/Exempt Institution _ Housing Abatement <br />Approx Dates of Occupancy -/-/- to _/ <br />hemical 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 />_ 1ITF MITIGATION: Environ Assess UST/CAP Loc Haz Waste Hai Mat PPL <br />Othar Lead Agency Site Agency: RWOCB DTSC NPL Site RB/1120 0 Other <br />_ Spin!) <br />WASTE: Landfill <br />Transfer Sta <br />Recycling Fac <br />A_ Waste Storage Fac Ag Waste/Exempt Site <br />check # Recvd Rv <br />SW Vehicle <br />No. <br />Dumrpster <br />No. Stationary Compactor Site <br />VECTOR <br />CONTROL: Poultry Farm Max Number <br />of Birds <br />Kernel <br />EMERC,FNCY <br />NOTIFII'CCATION, for <br />FACILITY aped/or PROGRAM <br />DAY NIGHT <br />CONTACT <br />-this <br />1 : �Gt cif (%✓\' <br />a� l � <br />(�by) 33y- o --- <br />CONTACT <br />2 <br />( ) <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/o <br />project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as th- <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 SIGNATU�: <br />i <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 />Fie Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />check # Recvd Rv <br />I <br />E <br />_1 <br />1 <br />Pi l!S I i✓t`�/yam/ I SUPV I --/--/ I ACCT / /--- I UNIT CLK I -/ -i <br />