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GENERAL PROGRAM FILE New 4"*Z Change ang Edit ��.•' (PROG3) revised 5/21/43 <br /> [RECORD <br /> ITY IO # i FACILITY NAME <br /> Sdj 5M r U <br /> ID # — PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in MuLti-Head Unit <br /> _ FOOD: Restaurant Market Cotttmissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/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/Motet No. of Units Jait/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: Poot/Spa Number of Pools <br /> Out of Service Pool Natural Bathing Place <br /> ,✓//SITE MITIGATION: Environ Assess UST/CAP v Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB 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 # % PROGRAM ELEMENT # 29 CURRENT STATUS <br /> # OF UNITS : /w EPA ID #: / INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of sane, 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, 1, the owner, operator or agent of sante, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirorntental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the sane time it is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ / SUPV / ACC UNIT CLK _/ / <br />