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GENERAL PROGRAM FiLE : New Chnnge 1/ Edit <br /> (PR?OG3) revised 5/21/93 <br /> FACiLIiY IDI O - —— FACILITY NAME <br /> RECORD IDX PRIOR SWFErS/COMP R <br /> DAIRY: Grade A Grade B Milk Dis"mer Ntrrbar of Containers in Multi-Heed Unit <br /> FOOD: Restaurant Market Comnissnry Mobile rood Produce Stand Ice Plnnt <br /> Seating Capacity SQ Ft _ _—.—_ Mnrket w/food rrer: Y / N <br /> Temporary Food Facility Specinl Food Event venribiq Mnchlnes Number of Vending Units <br /> Food Vehicle Make Llcenae M Registration N Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PFRMIT rncility : CA CE FOR <br /> _ HOUSING: Hotel/Motel No, of Units Ja WExempt Institution Housing Abatement <br /> Employee Housing No. of Employees Arprnx Ontes of Occupancy _/ ! to <br /> LIQUID WASTE: Pumper Vehicle PLrr"r Ynrd Clromirnl Tolletw No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) Storage (11-50) — Stornge ( >50 > — Transfer Stn _ Ltd Hauler _ Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Nunher of rnols Out of Service Pool Natural Bathing Piece <br /> SITE MITIGATION: Environ Assess UST/CAr Loc Ilei Wnste Hez Met PPL <br /> Other Lead Agency Site Agency: RWOCR DTSC NPL Site R8/H2O 0 Other <br /> SOLID WASTE: LandfillTransfer Stn Recyclinq Fne Waste Storage Fac s t e� <br /> SU Vehicle No. Ot>meter No. Stet E( <br /> 19 W-- <br /> VECTOR CONTROL: Poultry form Mnx Nurtt. APR 1 7 1995 <br /> r of Blyds Kerxxl <br /> rte r r <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY PERMIT/SERWC@S <br /> CONTACT 1 t 90Y1A�2 Ac�yy%elro (-I1�4) 440 - -7700 (]r4) �B 902'7 <br /> E I <br /> CONTACT 2 GC0.I1AA T'J't YV0 <br /> OESIGNATED EMPLOYEE I PROGRAM ELEMENT I Zq_�j3 CURRENT STATUS <br /> k OF UNITS EPA iD I: INSPECTION CODE <br /> BILLING brd COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site end/or <br /> project specific PHS/.HD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this Toren. i also certify that I hnve prepared this application and that the work to be performed will be done <br /> in accoroance with all app icable SAN JOAOUIN C"TY Ordinance Codes, and/or Standards and State arid/or Federal laws. <br /> APPLICANT'S SIGNATURE �0N,v`iC-, In <br /> 1'f/�f Illl3 <br /> Title: �C N Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the nbove, when applicable, 1, the owner, operator or agent of same, of <br /> - ,xv_ pita r--ithcrize 'f•e release of anY end ail results, ge i t <br /> environren:�er r c cssessawnt information to SAN jCACU1N COUNTY PUBLIC HEAL18 SERVICES ENVIRONMENTAL H lTH 1 IS on <br /> It is available and at the same time it is provided to me or my representative. <br /> nee Amount } Amount Paid 'Delta of Payment ( Payment Type I Receipt M Check I Reevd By <br /> 7 i <br /> FREHS l i ` SUPV _!--/-- ACCT <br />