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} GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> ' FACILITY ID # S FACILITY NAME <br /> k <br /> RECORD ID # 3 D-5 PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade 8 Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand fee Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility CA CE PBR <br /> HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy �J / to <br /> y LIQUID'WASTE: Ptnpe 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 (11-50) _ Storage ( >50 ) _ Transfer Sta 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 K^ Loc Haz Waste Naz Mat PPL <br /> Other Lead Agency Site Agency: RWQCS OTSC NPL Site RB/H20 Q Other <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dempster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM C� ,DAY I �f ' NIGHT <br /> CONTACT 1 < ).f --+ ( )-C <br /> -,!Z <br /> '! Z <br /> CONTACT 2 ( ) <br /> DESIGNATED EMPLOYEE # 1�r I PROGRAM ELEMENT # l (q,Cj CURRENT STATUS <br /> # OF UNITS EPA IID #: 5! sy 0 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. 1 also certify that I have prepared this application and that the work to be performed will 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 : �� Q.�" <br /> Title• 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 Located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/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 # Check # Recvd By <br /> RENS / / SUP' /�J ACCT / UNIT CLK �_f <br />