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/�/�crae. �'d�r tl fCc c i l rfy -f�✓ l a� "��I Cd�'�e�j ortt � ,a� <br /> CENE�AL PROGRAM FILE New Change Edit _ (PR0G3) revised 5/21/93 <br /> PICILITY ID # ^�/ FACILITY NAME — <br /> RECORD ID # PRIOR SWEEPS/COMP # D W p <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 F[ Market u/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 1 3 Co 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 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: RWOCB DTSC NPL Site _ RB/H20 Q 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 Number of Birds Kennet <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # f'( ( PROGRAM ELEMENT # / CURRENT STATUS <br /> # OF UNITS l.• EPA ID #: ib o(lorG Z(rl I / 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. 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 /> enviromentaL/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 At Recvd By <br /> REHS SUPV _/�/_ ACCT / / UNIT CLK _/ /_ <br />