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Page 2 GENERAL PROGRAM FILE (PROG3) revised 5/12/93 <br /> FACILITY ID # FACILITY NAME ,n�. <br /> • RECORD ID # 0(-) ( G / PRIOR DIST # PR OR SWEEPS/C/OMP # / 1 <br /> DAIRY: Grade A Grade B _ Milk Dispenser _ Number of Containers in Multi-Head Unit l� l <br /> _ FOOD: Restaurant Market Commissary _ Mobile Food _ Produce Stand _ Ice Plant _ <br /> Food Vehicle _ Make License # Registration # Color <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N # of Vending Machines <br /> HOUSING: Hotel/Motel No. of Units _ Jail _ Employee Housing _ No. of Employees <br /> LIQUID WASTE: Pumper Vehicle _ Pumper Yard _ Chemical Toilets _ No. Package Tx Plant <br /> RECREATIONAL HEALTH: POOL/Spa Number of Pools Out of Service Pool _ Natural Bathing Place _ <br /> V SITE MITIGATION: Environ Assess UST/CAP oc 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/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 <br /> • CONTACT 1 : <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # G1 E'j Gl 7- PROGRAM ELEMENT # Z Z/. CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #• INSPECTION CODE <br /> Number of TANKS Linked to this PROGRAM record Approx Occupancy Dates _/_/_ to <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and 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 /> • DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Jr <br /> l <br />