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0Change <br /> Edit (PROG3) revised 5/21193 <br /> r— <br /> GENERAL PROGRAM FILE : Net --� <br /> FACILITY NAME <br /> FACILITY ID # <br /> PRIOR SWEEPS/COMP # <br /> RECORD ID # <br /> Milk Dispenser Number of Containers in Multi-Head Unit <br /> DAIRY: Grade A Grade B <br /> r` Cortmissary Mobile Food Produce Stand Ice Plant <br /> FOOD: Restaurant Market Y 1 N <br /> -- Sq Ft � Market w/food Prep: <br /> Seating Capacity Vending Machines Number of Vending Units <br /> Temporary Food Facility Special Food Event Registration # Color <br /> Food Vehicle <br /> Make License # <br /> TIERED PERMIT Facility : CA <br /> CE PBR <br /> HAZARDOUS WASTE: Tons Generated/Yr �� <br /> its f U <br /> No. onJail/Exempt Institution Housing Abatement <br /> / <br /> HOUSING: Hotel/Motel Approx Dates of occupancy to <br /> ! <br /> Employee Housing � <br /> No. of Employees �� <br /> Chemical Toilets No. Package Tx Plant <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard <br /> Lg Generator sm Generator <br /> Acute Care Skilled Nursing Vet Clinic <br /> MEDICAL WASTE: Primary Care storage ( X50 ) � Transfer Sta , Ltd Hauler <br /> storage (2-10) Storage C11-50) <br /> Out of Service Pool Natural Bathing Place <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools <br /> UST/CAP Loc Haz Waste Haz Mat PPL <br /> SITE MITIGATION: Environ Assess DISC NPL Site R8/H20 0 Other <br /> other Lead Agency Site <br /> Agency; RWQC6 <br /> Recycling Fac Waste storage Fac Ag Waste/Exempt Site - <br /> SOLID WASTE: Landfill Transfer Sta Dempster No. Stationary Compactor Site <br /> SW Vehicle No. --—�- <br /> VECTOR CONTROL: Poultry Farm <br /> Max Number of Birds �� Kennel <br /> DAY NIGHT <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM <br /> CONTACT I - <br /> CONTACT 2 <br /> PROGRAM ELEMENT # r `f-'�v' CURRENT STATUS <br /> DESIGNATED EMPLOYEE # �' <br /> INSPECTION CODE <br /> # OF UNITS EPA ID #: <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/END 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 C Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Date:_ <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> e of any and all results, geotechnical data andlor <br /> the property located at the above site address hereby authorize the releas <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 ar my representative. <br /> 17 Date of Payment Payment Type Receipt # Check # Recvd By <br /> Y <br /> Fee Amount Amount Paid <br /> E <br /> �/ / ACCT / UNIT CLK �/ / <br />