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N z <br /> GENERAL PROGRAM FiLE New Edit <br /> (PROG3) revised 5/21/43 <br /> FACILITY 10 ! /� FACILITY NAME Lodi Site <br /> t� 6349 E <br /> RECORD ID ! a PRIOR SWEEPS/Camp ! <br /> DAIRY: Grade A Grade B Milk Dispenser Ntsnber of Containers in Multi-Head Unit _ <br /> FOOD: Restaurant Market Commissary _T Mobile Food Produce stand lee Plant <br /> Seating Capacity Sq Ft __ --- Mnrket w/rood Prep: Y / N <br /> Temporary Food Facility Special Food Event __ Venditiq Mnehlnes Number of Vending Units <br /> Food Vehicle Make Licenoe N _ Registratioii d Color <br /> HAZARDOUS HASTE: Tons Generated/Yr _ TIERED PERMIT racltity : CA CE POR <br /> HOUSING: Hotel/Motel No. of Units Jait/Exempt Institution Housing Abatement <br /> Employee Housing No, of Employees _ Approx Dates of Occupancy / / to <br /> LIQUID WASTE: Pumper Vehicle Ptm�per Yard Chr.micat Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) ^ Storage 01-SO) — Storage f >50 ) Transfer Ste Ltd Hauler J Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa HLmber of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Ila: Waste Her Mat PPL <br /> other Lead Agency Site Agency: RWOCH Disc NPL Site R9020 0 Other —_ <br /> research boring <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fee Ag Weate/Exertpt Site <br /> SW vehicle No. Dempster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Hu brr of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NiGHT <br /> CONTACT t't ERM — West Jeff Rubin) 946_-_ Q455 <br /> CONTACT 2 <br /> DE$[GNATED EMPLOYEE ! PROGRAM ELEMENT ! � 2 CURRENT STATUS <br /> ! OF UNITS : � EPA iD 0: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that alt site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity wilt be bitted to the party Identified as the <br /> BILLING PARTY on this form. 1 atso certi a prepared this application and that the work to be performed wilt be done <br /> in accordance with alt applic to SAN OAGUIN COUNTY Or inance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SiGNATLIR C fps S <br /> TitEe: MA OC14 Cf Dete: '� A� -- <br /> AUTHORIZATION TO REMSE INFORMATION: in addition to the above, when applicable, 1, he owner, operator or agent of same, of <br /> the property`locatod at the above site address hereby authorl-te the release of any and sit results, geotechnical date and/or <br /> environmentat/sit• 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 M Check ! Recvd By <br /> r -- <br /> REHS �s�/ �� / SUP.V / ��-/- - ACCT �W/ Lv/ UNIT CLK <br />