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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # 1�/ rte' FACILITY NAME <br /> RECORD ID # �� /.) -6,' PRIOR SWEEPS/CCMP f V1C0-HT <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 Scl Ft Market w/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 _/ /_ to _/ <br /> _ LIQUID WASTE: Pumper Vehicle Puryer 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 /> _/ <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste _ Haz Mat PPL _ <br /> Other Lead Agency Site / Agency: RWQCB ✓ DTSC NPL Site -RB/H20 Q _ Other _ <br /> OLID WASTE: Landfill _ Transfer Sta _ Recycling Fac Waste Storage Fac _ Ag Waste/Exempt Site <br /> SW Vehicle _ No. Duipster _ 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 # 7-� PROGRAM ELEMENT # L it it CURRENT STATUS <br /> # OF UNITS : EPA ID #: V INSPECTION 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. I also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards amid State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title- 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 /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RE HS _/_/_ SUPV `!Y ACCT 1J ,/, / UNIT CLK <br />