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GENERAL PROGRAM FILE New Change Edit (PROCT) revised 5/21/93 <br /> FACILITY ID A !J6 FACILt" NAME <br /> RECORD TO A �7 �VJ� PRIOR SNEEPS/CCHP M <br /> , <br /> _ DAIRY: Grade A Grade B Milk Oispenew _ Ntnber of Containers in MuLtl-Hard Unit <br /> FOOD! Restaurant Market _ Coamissary, _ Mobl to Food _ Produce Stand _ Ice Plant <br /> Seating Capecity Sq Ft Hark*t w/Food Prep: Y / N <br /> Temporary Food Faculty _ Special Food Event _ Yarding Hachines — Number of Vending Units <br /> Food Vehicle Make Lieersse ! Registration t rotor <br /> HAZAROCUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ PSR <br /> _ HWSING: Hotel/Hotel No. of hits Jail/Exeapt Imtitut ion Mousing Abatement <br /> Eaployee Housing _ No. of Eaptoyees Approx Dates of OcctgencY _/_J_ to J_J_ <br /> _ LIQUID WASTE: Purger Vehicle Purpar Yard _ Chealcal Toilets _- No. Package Tx Plant _ <br /> _ MEOIrAL WASTE: Prlamry Care Awte Care _ Skilled Nursing _ Lg Gararetor ` Sia Generator T <br /> Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) _ Transfer Sta __ Ltd Houter __ Vet Clinic <br /> /RECREATIONAL HEALTH: Pool/Spa Mudr of Pools Out of Service Pool _ Natural Bathing Place <br /> V SITE MITIGATION: Envirm Assns UST/CAP Loc Haz West* _ Hex Nat PPL _ � <br /> Other Lead Agency Site L_� Agency: RUQCB '✓ DTSC � NPL Site __ U/1120 a _ Other C? <br /> _ SOL 10 WASTE! Lancif lit Transfer Ste _ RecyclIng Fac _ Waste Storage Fac _ Ag Waste/Exempt Site <br /> SU Vehicle Mo. Dtapster _ No. Statiorsry Cospoctor Sita _ <br /> j VECTOR CONTROL: Poultry Fars_ Max Number of Birds - Knrrt _ <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 : <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE ? l � � PROGRAM ELEHENi ! '),I Sl QAIRENT STATUS <br /> A OF UNITS I EPA ID 2: v INSPECTION CCOE - -�G t� <br /> BILLING and CCMPLIANCE ACY.NCWLEDGEMENT: I, the u derslgrted owner, operator or agent of some, acknowledge that all size and/or <br /> project specific PHS/Elft) hourly charges assoclatd with this facility or activity WILL be bitted to the party Identified as the <br /> BILLING PARTY m this forr.- I also certify that I hav* prepared this appticatlm *rad that the work to be perforard will be done <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards <br /> ��aannfdr tTState aid/or Federal laws. <br /> APPLICANT'S SIGNATURE � -.D � " (Jei rc <br /> Title! �pro!.Pih' /-}F�[� /�y'1 `-� Date: l�t / <br /> AUTIPOR17ATIC4 TO RELEASE INFORMATION! In additlm to the above, when applicable, (, the awrrr, operator or agent of Sana, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> emirovrncal/Slee assessment Inforastion to SAN 30=111 COUNTY PUBLIC HEALTH SERVICES EMVIROMMENTAL HEALTH DIVISION as scot m <br /> It Is available and at the same time It Is provided to m* or any representative. <br /> Fee Muret Aoount Paid Date of Payment Payment Tyle Reeelpt A Check A Recvd By <br /> REHS �_/— �J—/— AST �/ Jy UNIT ax .J_l_ <br />