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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 8/26/93 <br /> FACILITY ID # FACILITY NAVE <br /> RECORD 10 # PRIOR SWEEPS/CCMP If <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 Vanding unite <br /> Food Vehicle Make License 0 Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT I.Itity : CA _ CE _ FOR _ <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 Pumper 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 (11-80) _ storage ( A50 ) Transfer Its _ Ltd Neuter _ vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa _ Number of Pools Out of Service Pool _ Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP _ Loc Haz waste _ Hex Mat PPL _ <br /> Other Lead Agency Site _ Agency: RWQCB DISC NPL Site _ RB/H20 0 _ Other <br /> SOLID WASTE: Landfill Transfer Sta _ Recycling Fac waste Storage Fac _ Ag waste/Exempt Site <br /> SW Vehicle No. Dumpster _ No. Statlonary Compactor Site <br /> ` VECTOR CONTROL: Poultry Form _ Max Number of Birds Ke not <br /> EMERGENCY NOTIFICATION for <br /> , this FACILITY and/or PROGRAM <br /> I� DAY NIGHT <br /> CONTACT 1 a, Lw od Jho ALw (222A7$ -9 200 (Ze0 <br /> CONTACT 2 : w Zc (oQu) 5bo - 4-col _ (6,Q-) F%- <br /> DESIGNATED EMPLOYEE # I PROGRAM ELEMENT # �— .S CURRENT STATUS <br /> # OF UNITS : EPA ID #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the Undersigned owner, operator or agent of sew, acknowledge that all site and/or <br /> project specific PHS/END heady charges associated wi this facili ctivity be.billed to the party Identified as the <br /> BILLING PARTY on this form. I also e 1 y th Ve r lin on that the to be performed will be done <br /> In accordance with ell applicabl OtlI Y Ordf and/ star ds and federal is". <br /> APPLICANT'S SIGNATURE : <br /> s / <br /> Titte: 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 el( results, geotechnical data and/or <br /> envirorntental/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 0 Check # Recvd By <br /> RENS ___/_�_ SUPS _/-J- ACCT �_J- <br />