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GENERAL PROGRAM FILE New Chnnge Edit (PROG3) revised 5/21/03 <br /> FACILITY iD / (j am, � -- FACILITY NAME ♦/�f,s 6WIC-41V :✓jQwly4 S <br /> I�Lv�/�'�,�• <br /> RECORD ID 0 ( PRIOR SWEErs/Comp 0 - t e <br /> DAiRY: Grade A Grade B Milk DixMm er Ntsrber of Containers in Mutti-Head Unit <br /> _ F000: Restaurant Market Commissary Mobile rood Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/rod Prer: y / N <br /> Temporary Food Facility Special Fnod Evnnt Vending Mnclrines Nufber of Vending Units <br /> Food Vehicle Make License M Registration M Color <br /> HAZARDOUS WASTE: . Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Arprox Dates of Occupancy _/ / to <br /> LIOU10 WASTE: Pumper Vehicle Pumper Yard Clee•mical Toilets No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-SO) Stornae ( >SO ) Tron-tfer Ste Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Nurrt+Pr of Pneis Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP lac flax Waste Nez Mat PPL <br /> Other Lead Agency Site Agency: RWOCR DISC NPL Site R8/H2O 0 Other <br /> _ SOLID WASTE: Landfill Transfer Stn Recyciina me Waste Storage Fee Ag Waate/Exempt Site <br /> SW Vehlete No. DtzrTmter No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Form Max Nual. r of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FfACCiLITY and/or PROGRAM ,i,y DAY NIGHT <br /> CONTACT 1 t ROY)n` e. 1� `tom��C� •-- ( 114) 44c - -7-7oo ( 14 _r'gg 0 2- <br /> - <br /> CONTACT 2 ( 2 01) 54`' ITTp <br /> DESIGNATED EHPLOYEE aY ��Z <br /> L! PROGRAM=FL— <br /> I <br /> C CURRENT STATUS / '-� i <br /> OF UNiTS EPA iD fl: INSPECTION CODE : <br /> BILLING brd COMPLIANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project 4pecific PHS/:HD hourly charges associated with this facility or activity wilt be billed to the party identified as the <br /> BILLING PARTY on this Torm. i atso certify that I have prepared this application and that the work to be performed will be done <br /> in accoraance with all app lcoble SAN JOAOUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal taws. <br /> APPLICANT'S SIGNATURE : �C �DNNI1:::F <br /> Title: e VA e-f Date: Page 10B <br /> AUTHORIZATION TO RELEASE INFORMATI N: in addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> :`.b -rcfYrty at s!te _K�rzss "_re^r "ithf`r!ie he relerse of any end at( results, geotechnical date and/or <br /> environxent2t, :;::r: cssessment information to SAN .iGACU1N COUNTY PUBLIC HSAIIH SERVICES ENVIRONMENTAL HEALTH DIVISION ss Soon as <br /> It is available and at the same time It is provided to me or my representative. <br /> lee Amotau I Amount Paid Date of Payment iPayment Type i Receipt A Check B Reevd By <br /> 1 1 1 <br /> — --T--- i <br /> REHS SUPV _i—_1- ACCT i" •7/ UNIT CLK <br /> to •--...-- -. _. --- - - ----•- f -- ----- <br />