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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> !ACILITY ID # T� FACILITY NAME <br /> RECORD 10 # —=PRIOR SWEEPS/COMP # 5 <br /> DAIRY: Grade A Grade 6 Milk Dispenser Number of Containers in Mu'ltiLA <br /> FOOD: Restaurant _ Market Commissary _ Mobile Food _ Produce Stand _ Ice Plant <br /> Seating Capacity Sq Ft Market u/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/Motel _ No. of Units Jail/Exempt Institution Housing Abatement _ <br /> Employee Housing _ No, of Employees Approx Dates of Occupancy _J_/_ to <br /> :C'UID WASTE: ..:ry=: :ehfcle _ Puper 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 Sta _ Ltd Hauler _ Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool _ Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Naz Waste k Naz Mat PPL _ <br /> Other Lead Agency Site _ Agency: RWOCB DTSC _ NPL Site _ RB/H20 0 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 Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 : <br /> CONTACT 2 : ,,�( ��) ( ) <br /> DESIGNATED EMPLOYEE # 2 PROGRAM ELEMENT # ;,15,�.rS 1 CURRENT STATUS <br /> E 4 <br /> OF L'X1 TS . EPA In #• d" ✓ 1ugDECT:CH CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, 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. 1 also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all appLfcable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> ,I <br /> Title: 1 i.__, 1 ' Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 JOAQUIN 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 /> Fete(Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> M <br /> J 1 v n <br /> SUPV _/ /_ ACCT _/ /_ UNIT CLK _/_/_ <br />