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r <br /> GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID ! � _ FACILITY NAHE <br /> RECORD ID ! PRIOR sWFEPSICOMP ! <br /> DAIRY- Grade A Grade 8 Milk DispeneerT4 n Number of Containers In Multi-Head Unit <br /> FOOD: Restaurant Market ComrmlaRnry Mobile Food Produce Stand ice Plnnt <br /> r Seating Capacity Sq Ft Market w/Food Prep Y / N <br /> Temporary Food FacItity Special Food Event Verding Machines Ntrrber of Vending Units <br /> Food Vehicle Make Licenee M Reolstrotimi M Cotor <br /> ' HAZARDCUS WASTE: Tons Generated/Yr TIERED PFRMIT Facility • CA CE PBR <br /> HOUSING hotel/Motel No. of Units Batt/Exeopt Institution Housing Abatement <br /> Emptoyee housing No of Emptoyees Approx Dates of occupancy �/ 1 to <br /> LIOVID WASTE- Pumper Vehicle Pumper Yard Ch.mleal lollets No Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) Storage (11-50) storoge ( 3.50 ) Tronsfer Sta Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> X SITE MITIGATION- Environ Assess X UST/CAP Loc liar Waste Nat Mat PPL <br /> Other Lead Agency Site Agency, RWOCR DTSC NPL Site RB/H20 O other <br /> SOLID WASTE Landfill Transfer Ste Recycling Fnc Waete Storage Fee Ag Waste/Exempt Site <br /> SW Vehicle Na DtirrKter No Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Numbrr of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> iCONTACT 1 : Mr Steve Peterson ( 209) 546-8249 (209 ) 956 ,_•�_ <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE N PROGRAM ELEMENT ! CURRENT STATUS j <br /> ! OF UNITS I EPA 10 ! 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 JOADU N COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> ' <br /> Title- Page 1013 <br /> Da <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 ell results, geotechnical data and/or <br /> envlronaentel/site assessment Information to SAN JOAOUIN 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 Anoint Amount Pold Date of Payment Payment type Receipt 0 Check ! Recvd By <br />� 1 <br /> ' RENS 1 1 dIPV ■r r r . .. , <br />