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GENERAL PROGRAM FILE New Chnnge Edit (PROG3) revised 5/21/93 <br /> FACILITY iD N 2 / FACILITY NAME <br /> RECORD ID 0 h S� PRIOR SWEEPS/COMP # <br /> — DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Mutti-Head Unit <br /> FOOD: Restaurant Market Comnissnry _ _ Mobile rood Produce Stand lee Plant <br /> Seating Capacity Sq Ft —_ Mnrket w/rood Prep: Y / N <br /> Temporary Food Facility Special rood Event Vending Machines Nurber of Vending Unita <br /> Food Vehicle Make Licence # Registratim # 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 _/ / to <br /> LIQUID WASTE: Pumper Vehicle Purger Yard _ Chomicat 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) __ Stornge ( >50 ) _ Trennfer Stn _ Ltd Hauler Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Nuurher of Pools _ —,_ Out of Service Pool Natural Bathing Place <br /> X SITE MITIGATION: Environ Assess _X UST/Cllr _ toc Haz Waste Hez Mat PPL <br /> Other Lead Agency Site Agency: RWOCR _ DISC NPL Site RB/H2O 0 Other <br /> _ SOLID WASTE: Landfill Transfer Stn —_ Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. DrmTcter ___ No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Nurtv+r of Birds —_ _ Key"I <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 <br /> DEtIGNATED EMPLOYEE 0- rROCRAM ELEMENT # �J j CURRENT STATUS <br /> # OF UNITS : EPA iD 9: y INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNLVLEDGEMENT: I, the undersigned owner, operator or agent of Same, acknowledge that all site and/or <br /> project specific PHS/vHD hourt chargee associated with this facility or activity will be bitted to the party identified as the <br /> BILLING PARTY on this forth. also c t y th t I have prepared this application and that the work to be performed wit( be done <br /> In accoraance with alt a i able N ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Page 1011 <br /> Title: Prole t Manager er Date: R Marrh 199 <br /> AUTHORIZATION TO R L ASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the rcherxy rut°: abc.'z, ?!t4 actress !erebw authorize the relessM cf any end all results, geotechnical data and/or <br /> environnentst/::(cc czaesw.tent Infcrmation to SAN JOACU1N 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 /> Fee Amount Amount Paid Ddte of Payment ir'a�ymxnt type R"eipt # check R Recvd By <br /> � f � + oat <br /> [ EHS �/ ! SUPY — f____/ ACCi �/ �/ UNIT CLK _/ / <br />