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GENERAL PROGRAM FILE New Change Edit (PROG3I.) revised 5/21/93 <br /> FACILITv to # ���ja � ; L i'1AWCILATY NAME' CARS/GC Pt�/PT �v 8 f � LJT`l' <br /> Yi <br /> x s RECORD ID # ' �"UG�OI r PRIOR SWEEPS/COMP # <br /> Dispenser Number of Containers in Multi-Head Unit J/_ <br /> OAIRY: Grade A Grade B Milk K <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant ;' <br /> ' Seating_Capacity Sq Ft Market w/Food Prep: Y `% " M <br /> »" <br /> ..,. x .w <br /> Temporary Food Facility Special food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # Color .t <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility CA CE PBR�' ' <br /> HOUSING: Hotel/Motel L No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees �Approx Dates of Occupancy _J_/ to <br /> _ LIQUID WASTE: Pumper Vehicle Pumper Yard' Chemical Toilets No. Package _Tx Plant <br /> _ MEDICAL WASTE: Primary Care ' n Acute Care Skilled Nursing Lg Generator�t 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-BathingLPlace <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H2O 0 Other '! <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Du Aster No. Stationary Compactor Site <br /> VECTOR CONTROL: PoultryFano Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM ". .. DAY '` NIGHT' <br /> 'J tom-p���3- o�l16" <br /> CONTACT 1..• Yr/r� 1t OL ( ��O"_'.'.'7/ < ) <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # 6 Q PROGRAM ELEMENT # ��p b CURRENT.STATUS <br /> # OF UNITS EPA ID #: INSPECTION CODE ; <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledgef,I, iata site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the lied as the <br /> R TI <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be pehformed"wtill be done ._ . <br /> in accordance with all applicable SAN JOA OUNTY Ordinance and or Standards and State and/f[FOeJaWLT,rS6 <br /> "7 SAN JO4OUI1y U�� ) U <br /> APPLICANT'S SIGNATURE /j <br /> e� kVIR'ONMENTAL H�SERVICES <br /> Title: .S`L/�' /N�''�.lD 7yJ- Date: Zr ALTHDIVISION' <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 /> itis avai lable'and at.the same time it is provided to me or my representative. Qa <br /> Amount Amount Paid Date of Payment Payment Type . Receipt # Check # Recvd By <br /> a RENS. LI I / SUPV _/__/ a ACCT o�/ l / UNIT CLK ! J <br />