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GENERAL PROGRAM FiLE New Cham%ge Edit (PROG3) revised 5/21/93 <br /> FACILi7Y ID N FACILITY NAF¢ <br /> RECORD ID ! PRIOR SWEEPS/COMP R <br /> DAIRY. Grade A Grade I Milk Dlapenner Number of Containers In Muttl-Need Unit <br /> FOOD Restaurant Market commi.sary __ Mobile rood Produce Stand ice Plant <br /> Seating Capacity Sq Ft Market w/rood Prep Y / N <br /> Temporary Food Facility Special food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License if _ Re9tstration M Color <br /> HAZARDOUS WASTE- Tons Generated/Yr TIERED PFRMIT Focllfty - CA CE FOR <br /> HOUSING. Hotel/Motel No of Units ,tall/Eaeept Institution Housing Abatement <br /> Employee Housing No. of Errptoyeen Arrcox Dotes of Occupancy _/ / to <br /> LiQUID WASTE- Ats per Vehicle Ptamper Yard rhemicel Toilets No Package Tx Plant <br /> MEDICAL WASTE- Primary Care Acute Care Skflled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( X50 ) Tronfifer Sts Ltd Neuter T Vet Clinic <br /> RECREATIONAL HEALTH- Pool/Spa Hunner of Pools out of Service Pool Natural Bathing Place <br /> X SITE MITIGATION, Environ Assess X UST/CAP lac fiat Waste Hex Mat PPL <br /> Other Lead Agency Site Agency: RWOCR DiSC NPL Site RB/HZO 0 Other <br /> _ SOLID WASTE- Landfill Transfer Ste Recycling Fee Waete Storage Fee Ag Waste/Exempt Site <br /> SW Vehicle No Dia"ter No Stationary Compactor Site <br /> t <br /> VECTOR CONTROL: Poultry Farms Max Nufb-r of Bfrd4 Kennet <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT t t Mtke Wallace_ (Cay-of_Stockton) U09) 937 -Sfi28 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE $ PROGRAM ELEMENT / CURRENT STATUS <br /> ti <br /> t OF UNIT$ EPA 10 R• INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent of some, acknowledge that all site and/or <br /> project specific PNS/END hourly charges associated with this facility or activity will be bitted to the party identified as the <br /> BILLING PARTY on this Iona. i also certify that I have prepared this application and that the work to be performed wilt be done <br /> In accordance with alt applicable SAN JONDUINEZ, <br /> Ordlnonce Codes and/or Standards and State and/or Federal taws, <br /> APPLICANT'S SIGNATURE G <br /> r <br /> Title: /��y�_ _ � _ Dote* �=%9G 1 ff e 1(JB <br /> AUTHORIZATION TO RELEASE INFORMATION in addition to the above, when epplfcable, 1, the outer, 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 date and/or <br /> envirormentol/site assessment information to SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAf,TH DIVISION as soon as <br /> It Is avellable and at the same tiae It is provided to me or my representative <br /> Fee As�utt Amoint Paid Date of Psyment Payment Type Receipt A Check B Recvd By <br /> RENS - �J / WPV �/ / ACCT _/ / UNIT CLK _/ / <br />