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GENERALPROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> .� <br /> —T <br /> FAGiLITY ID N 7,2 FACILITY NAME <br /> J <br /> RECORD [D 0 / PRIOR SWEEPS/COMP N <br /> DAiRY: Brads A Grade 8 Milk Dispenser Number of Containers In Multi-Head Unit <br /> FOOD: Restaurant Market Comnlssnry ___.-_._ Mobile rood Produce Stand lee Plant <br /> Sea tIrV Cepae[ty Sq Ft - Hnrket w/Feed rreC: Y / N <br /> Temporary Food Facility Special Food Event vending Machines Number of Vending Units <br /> Food Vehicle Hake Llcente N _ Regiatratiori N Color <br /> f <br /> HAZARDOUS VASTI : Tons Generated/Yr _ TIERED PFRHIT racllity CA CE POR <br /> _ HOUSING. Hotel/Motel No. of Units .tail/Exert Institution Housing Abatement <br /> Employee Housing No. of Employees _ Arprox Dates of Occupancy _/ / to <br /> LIOUID WASTE! Pumper Vehicle Pumper Yard Chomlcal Toilets No. Package Tx Plant <br /> MEDICAL WASTES Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage t >50 ) Transfer Ste Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: POOL/Spa Numher of Poots Y Out of Service Pool Natural Bathing Place <br /> i SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Hat PPL <br /> Other Lead Agency Site 0- Agency: RWOCB DiSC HPL Site RG/H70 Q Other <br /> SOLID WASTEf Landfill Transfer Sto # Recycling me Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Du -K ter No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> i <br /> CONTACT i't <br /> CONTACT 2 <br /> DEN GNATEd EMPLOYEE # D jPROGRAM ELEMENT N a Lj SD CURRENT STATUS <br /> N OF UNITS EPA iD R: INSPECTION CODE <br /> BILLING Ord COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ail site and/or <br /> project specific PNS/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 JIN COUNTY Ordloprice Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S CIGNATURE +!/� <br /> Title: (fit g40-L,.Ca e,, —ccfv D CJO Date: s`7✓ ! f'o Page IOB <br /> AUTHMIZATIOW TO RELEASE [M NATION: In Iddition to the above, when applicabl , 1, thi owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of tiny and all results, geotechnical data and/or <br /> environmental/site assestment 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 Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> REHS ___i I SUPVE //---��_ ACCP �K -L� 1 �� UNIT CLK �/ / <br />