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•GENE+AL PROGRAM FILE Nen Change Edit (PROG3) revised 8/26/93 <br /> FACILITY 10 # / 7 ( FACILITY NAME <br /> RECORD ID # SDS X 77 1PRIOR SWEEPS/Culp M <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary 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 V"Ine Units <br /> Food vehicle Make License N Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PSR <br /> _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy _J_J 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 Sts Generator <br /> Storage (2-10) Storage (11-50) _ Storage ( >90 > Transfer Ste Ltd Hauler _ Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> r SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste _y_ Naz Mat PPL <br /> Other Lead Agency Site Agency: RWOCB DTSC NPL Site RB/H2O 0 Other <br /> _ SOLID WASTE: Landfill Transfer Sta 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 Kernot — <br /> EHFRGEIlCY NOTIFICATION for this FACILITY and/or PROGRAM <br /> DAT NIGHT <br /> CONTACT 1 <br /> CCNT.ACT 2 ( ) ( ) <br /> DESIGNATED EMPLOYEE # ob PROGRAM ELEMENT is z '53 CURRENT STATUS <br /> N OF UNITS EPA ID #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sass, acknowledge that all site and/or <br /> Gproject 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 witl be done <br /> in accordance with all applicable SA JOA iN'COL41 Ordinance Codes and/or Standards and State and/°r Federal Sews. <br /> APPLIZANT•S SIGNATURE <br /> i <br /> Zz�,g - <br /> V If <br /> Ti tte: v / f//( r0 NIGkS�QI� G tX/-�A x/61 X71 P;_ Date: f /f <br /> AttTHr,RIZATION TO RELEASE INFORMATION: In addition'to the above, when applicable, I, the owner, operator or agent of seise, of <br /> the property Located at the above site address hereby authorize the retease of any snd all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRdMENTAL 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 Date of Payment Payment Type Receipt 0 Check 0 Reevd By <br /> - Ou <br /> FEE_/_� SUP/ _/_f� 11111T CLK <br />