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GENER„L PROGRAM FILE : New 0 Change Edit (PR0G3) revised 5/21/43 <br /> FACILITY 1D # <br /> Yvj} 170q�} FACILITY NAME �� c, i <br /> RECORD ID # ��Q�5 Cq/ / PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B 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 _ Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr r �T 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 <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 Yet Ctinic <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/1420 Q Other <br /> _ SOLID WASTE: LandfiLL Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SLI Vehicle No. Oumpster 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 1 +-- � PROGRAM ELEMENT # f �. CURRENT STATUS <br /> /� <br /> r� <br /> # OF UNITS : EPA ID #: �,'a q� 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 availabte 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 /> UNIT CLK <br /> REHS _!,J SUPV _/ / ACCT / 3/ ,/� <br />