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' I <br /> GENERAL PROGRAM FILE Neu ` Change Edit f (PROG3) revised 5/21/43' <br /> � , <br /> FACILITY ID # FACILITY NAME, <br /> Gu'}� <br /> RECORD ID # PRIOR SWEEPS/COMP # r <br /> _ DAIRY: Grade A Grade a Milk Dispenser Number of Containers in Multi-Need Unit <br /> i <br /> _ FOOD: Restaurant Market Commissary Mobite Food - Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y' N <br /> Temporary Food Facility Specia0 Food Event ' Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # r color <br /> _ HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT 'Facility : CA CE PSR <br /> HOUSING: Hotel/Motel No. of Units Jait/Exempt Institution 'Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupency f /, to <br /> } <br /> LIQUID WASTE: Pumper Vehicle Pumper,Yard Chemical Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled NursingLg Generator Sm Generator <br /> Storage (2-10) Storage (11-50) _ Storage ( >50 } Transfer Sta Ltd Hauter _ Vet Clinic <br /> _ RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> 1 <br /> SITE MITIGATION: Environ Assess UST/CAP Loc HaZ WasteHaz Mat PPL <br /> Other Lead Agency Site Agency: RWOCB DTSC NPL Site R8020 a Other <br /> SOLID WASTE: Landfill ... Transfer Ste Recycling Fee Waste Storage Fac As-Waste/Exempt Site 111 <br /> SW Vehicle No. Oumpster No:, Stationary Compactor Site. <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds c Kennel,.. . <br /> EMERGENCY NOTIFICATION for this FACILITY and/or'PROGRA14 DAY NIGHT <br /> CONTACT 1 ( ) { ) <br /> CONTACT 2 ( ) C ) <br /> -T <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> r <br /> it OF UNITS EPA ED #: iNSPECTIOM CODE .... <br /> SELLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned:owner, operator or agent of same, acknowledge-that all site and/or. <br /> project specific PHS/END hourly charges associated with this facility or activity will be bitted to the party identified as the <br /> BILLING PARTY on this form. I also certify thstI have prepared this apptication-and that the work to be performed wilt be done <br /> in accordance with alt applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE 1 <br /> Titte: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable,::°I, the owner, operator or.agent of,same, of <br /> the property bated at the above site address hereby authorize the release of any and-att results,.geotechnical data and/or <br /> environmentat/site assessment information to SANiJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as $oon 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 it Check #' Recvd BY E + <br /> 75Q 0 sr <br /> 7i <br /> RENS _ f SUPV I ACCT UNIT CLK <br /> k <br /> II I y = <br /> J <br />