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GENERAL PROGRAM FILE New _ Charge Edit <br /> (PROG3) revised 8/26/93 <br /> FACILITY (D Al FACILITY NAME <br /> RECORD 10 x PRI0R SWEEPS/CORP 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 MachinaA _ Number of Vendina Unita <br /> Food Vehicle _ Make License / Registration R Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ PBR <br /> HCUSING: 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 (11-30) _ storage ( 150 ) Transfer Ste _ Ltd Hauler _ 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 Hat Waste _ Hat Mat PPL _ <br /> Other Lead Agency Site _ Agency: RWOCB DISC _ NPL Site _ RS/H2O 0 Other <br /> SOLID WASTE: Landfill Transfer Sta _ Recycling Fac Waste Storage Fee _ Ag Waste/Exempt Site <br /> SW Vehicle No. Oumpster _ No. Statiorary Compactor Site <br /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Xenyl <br /> EMERGENCY NOTIFICAATTION for this FACILITY TTY and/or PROGRAM DAT NIGHT <br /> CONTACT 1 rrTQ,v Lw "CAJrtCXLq((CCYnT('i—{� ✓ 'o3Aar <br /> . . rnyfra. <br /> CONTACT 2 1 L. C �ZLLi ( !V) 4-d C1 f <br /> DESIGNATED EMPLOYEE At PROGRAM ELEMENT s CURRENT STATUS <br /> s OF UNITS : EPA ID 0: - INSPECTION =E <br /> BILLING and COMPLIANCE ACXNOWLEDGEMENT: I, the undersigned owner, operator or agent of sial, acknowledge that ell site and/or <br /> project specific PHS/EHO hourly charges associated wi this facili o ctivity bfbllled to t party Identified as the <br /> BILLING PARTY on this form. I also c y the ve r lies on that the to be performed will be done <br /> in accordance with all appocabt M Y Ordi and/0 St rds and Laws. <br /> 'r <br /> APPLICANT'S SIGNATURE <br /> , <br /> Title. Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the caner, operwtor or agent of satyr, of i <br /> the property located at the above site address hereby authorize the release of any and sit results, geotechnical dots arcVor <br /> environmental/site assessment informetfon to SAN JOAWIN COUNTT 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 Payteent Type Receipt A Check S Recvd By <br /> r <br /> i <br /> t <br /> SUN AGCT UNIT CLX <br /> r <br /> i <br />