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GENERAL PROGRAM FILE Nein Change Edit (PROG3) rlevli4ed`5/21 93 <br /> FACILITY ID # / U6 FACILITY NAME �• ,� tyr I p _ i � <br /> RECORD ID # S J PRIOR SWEEPS/COMP # V l� �Z �XJ <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 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 TIERED PERMIT Facility : CA _ CE _ PBR <br /> _ HOUSING: Hotel/Motel _ No. of Units Jai L/Exempt Institution Housing Abatement <br /> Employee Housing _ No. of Employees Approx Dates of occupancy _�_/_ to _/_/_ <br /> LIQUID WASTE: Pumcer 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 _ Vet Clinic <br /> RECREATIONAL HEALTH: Poo(/Spa _ Number of Pools Out of Service Pool _ Natural Bathing Place <br /> SITE MITIGATION: Environ Assess ✓ UST/CAP _ Loc Haz Waste _ Naz Mat PPL _ <br /> Other Lead Agency Site _ Agency: RWQCB _ DTSC NPL Site _ RB/H20 0 _ Other <br /> _ SOLID WASTE: Landfill _ Transfer Ste _ Recycling Fac Waste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle No. Dunpster _ 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 I : !//�CLr J [A/,-f LI7 <�t��3 5`�5- Z/�s <?�"t ) 2q4 !. � <br /> CONTACT 2 I*A,57�-✓ <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # 2g45 CURRENT STATUS G <br /> # OF UNITS EPA ID #: ,�QJ 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 : -�i � c. <br /> Title: 0/QLrG762 Od / Cc.sL<,104-F5 Date: 2 COQ` <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 /> Fee Amount unt Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 390 <br /> REHS _/ /_ SUPV _/_/_ ACCT / ���/ "��/ �-� UNIT CLK _/_/_ <br />