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GENERAL PROGRAM FILE New change Edit (PROG3) revised 5/21/73 <br /> FACILITY 10 0 J3 FACILITY NAME <br /> RECORD ID 0 ` S�(O / PRIOR SWEEPS/CGMP N <br /> _ DAIRY: Grade A Grade B _ Milk Dispenser _ Number of Containers in Multi-Head Unit <br /> _ FOOD: Restaurant Market — Commissnry __ Mobile Food _ Produce St end _ Ice Plant _ <br /> Seating Capacity Sq Ft Mnrket w/rood Prep: Y / N <br /> Temporary food Facility _ Special Foci Event _ Vending Machines —Number of Vending Units <br /> Food Vehicle Make License R Registration 0 Color <br /> HAZARDOUS WASTE: Tons Generated/Yr _ TIERED PERMIT Facltfty - CA _ CE — FOR _ <br /> _ HOUSING: Hotel/Motel No. of Units Jail/Exeapt Institution Housing Abatement <br /> Employee Housing _ No. of Employees Approx Dates of Occupancy _/_/— to <br /> LIOUID WASTE: Pumper Vehicle _ Pumper Yard __- Chemical Tollets — No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care _ Acute Core _ Skilled Nursing _ Lg Generator _ Sm Generator _ <br /> Storage (2-10) _ Storage (11-50) _ Storoge ( >50 ) __ Transfer Ste _ Ltd Neuter _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool _ Natural Bathing Place _ <br /> V_/SITE MITIGATION: EnvirmnAs a�!s9 UST/CAP _ lac Haz Woste — Hot Met PPL — <br /> Other Lead Agency Site _ Agency: RWOCR _ DISC NPL Site — RB/1120 O _ Other _ <br /> _ SOLID WASTE: Landfill _ Transfer Ste ___ Recycling Fac Wnste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle No. OunTnter No. Stationary Compactor Site _ <br /> VECTOR CONTROL: Poultry Form _ Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY send/or PROGRAM DAY NIGHT <br /> CONTACT it <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE 6 '� PROGRAM ELEMENT A O� l✓ CURRENT STATUS <br /> If OF UNITS EPA 10 p: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that alt site amid/or <br /> project specific PNS/END hourly charges associated with this facility or activity will be billed to the party Identified as the <br /> BILLING PARTY on this form. 1 also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance w th all applicable SAN JOAO N COUNTY ordlJ11141ce Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE : klw <br /> ' x <br /> Title: �i;/ t'c� /eZ{Cf,a�,� Date: per. 22� /`� g �o Page a IOR <br /> AUTHORIZATION TO RELEASE INFORMATI N: In addition to the above, when applicable, 1, 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 JOAOUIN 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 M Check 0 Recvd By <br /> REHS _/_/_ SUPY ACCT 1/ / UNIT CLK <br />