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GENERAL PROGRAM FILE : New <br /> Change <br /> FACILITY IDN <br /> Edit <br /> _ (PROG3) revised 5/21/93 <br /> ------ -------- <br /> /-4)-/--/ Lft� �(�� —p(�,o-- p , FACILITY NAME <br /> RECORD IDN <br /> eR / 112 <br /> z <br /> r R K� PRIOR SUFEPS/CORP N <br /> DAIRY: Grade A _ Grade B Milk Dispenser <br /> PefserNurbe.r of Containers In Multi-Mead Unit <br /> -- FOOD: Restaurant __ Market Commissar <br /> Sestl Ca Y Mobile food <br /> n0 Capacity Sq it -- F'roltuce Stand _ Ice Plant <br /> Temporary Food Facility -------- Market w/Food Prep! Y / N -- <br /> Food Vehicle '— sleclet Food Event -- Verdirq Machines <br /> __ Make .__ Number of Vending Unite <br /> License N --- Regiatratim N <br /> Color <br /> _— HAZARDOUS WASTE: Tons Generated/Yr <br /> TIERED PERMIT Facllity : CA CE _ <br /> PRR <br /> Employes Housing NoNd _ <br /> HOUSING: Hotel/Motel - of Units _ <br /> __ <br /> Jeil/Exeopt Institution. of Employees Housing Abatement <br /> Approx Dates of Occupancy to <br /> ,-- MEDICAL <br /> WASTE: Pumper Vehicle <br /> Pumper Yard —_—_-_ Chmieal Tolleta No. <br /> Package Tx Pleat _ <br /> MEDICAL WASTE: Primary Care Acute Care _ <br /> Storage (2-1O) Storage (11.50) Skilled Nursing _ Lg Generator_ storage ( >50 Sin <br /> Generator <br /> _—_ Trens far Stn __ Ltd Hauler Vet Clinic <br /> _ <br /> _ RECREATIONAL HEALTH: Pool/Spa _ NLP+,er of Pools <br /> Out of Service Pool _ Natural Bathing Place _ <br /> X SITE MITIGATION: Environ Assess _ UST/CAr <br /> Other Lead Agency Site Loc Ilex Waste __ to Mat PPL _— <br /> Agency: R1gCfl Disc 1"�LC Sa,—rPl' <br /> -- NPL Site _ R8/H2O 0 _ Other Z(_lv <br /> _,_ SOLID WASTE: Landfill Transfer Stn Recycling Fee 1 - <br /> -- Y g Waste Storage Fac Ag Waste/Exempt site 67/zr--L <br /> SW Vehicle No. Durps ter <br /> No, Stationer Compactor ompector stto <br /> — VECTOR CONTROL: Poultry FormMax Maur of Blyds I'n <br /> Kennel _ <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM— <br /> DAY NIGHT <br /> CONTACT I iSr�-,moo,,. �. r; �,��1 cam, <br /> CONTACT 2 1�/L,r_ U srn,L— (2`=1) 9>z- 4 �Z � A— (__) <br /> A,i h S v c <br /> (Z�•i-zL 7 <br /> DESIGNATED EMPLOYEE RO IL7� PROGRAM ELEMENT N GCURRENT STATUS <br /> N OF UNITS EPA ID N: <br /> INSPECTION CODE : <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of Same, acknowledge that all site are(/or <br /> project spacfflc PHS/EHD hourly charges associated with this facility or activity will be billed to the party Identif led as the <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done <br /> In accordance with all applicabl SAN JOAOUI COUNTY OGrdJing Codes andards and State and/or Federal taws. <br /> APPLICANT'S SIGNATURE ; - ,-," f /NC/ <br /> A'S Oc <br /> Tltlet �F-1_ 5Fti--71Ncc/Z— Date: 2— Pope 1011 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, <br /> Lila r operator or agent of same, of <br /> property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormentel/sfte assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the Same time it I$ provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Cheek N Recvd By <br /> RENS /_/ SUPV _/_/_I ACCTf-- I <br /> / / UNIT rIK <br />