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.� <br /> Edit ��� (PROG3) revised 5/21/93 <br /> AM <br /> GENERAL PROGRFILE Nasi Change <br /> Illinois <br /> e. <br /> FACILITY NAME l '7 <br /> 7 e'a <br /> FACILITY ID oa3K,;:r.� <br /> RECORD IA <br /> PRIOR SNEEPS/COUP <br /> # �3<p <br /> t _DAIRY: Grade A Grade 8 Milk Dispenser Nuaber of Containers in Mufti-Head Unit <br /> Coemiseary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity S4 Ft <br /> F000: Restaurant Market Market w/Food Prep: Y / N <br /> --�-�— units <br /> Special Food Event Vending Machines Nusber of Vending <br /> Temporary Food Facility Pen Registration it Color <br /> 4 Food Vehicle Make License <br /> HAZARDOUS <br /> PERMIT Facility : CA CE PSR <br /> vASTE: Tone Generated/Yr <br /> Jail/Exempt institution Housing Abatement <br /> HOUSING: Notel/Matei No. of Units <br /> Approx Dates of OecupencY <br /> Employee Housing No. of Ecployees r,^/��� <br /> LIQUID HASTE: Pumper Vehicle Pumper Yard chemical Toiteta No. <br /> Package Tx Plant <br /> +— MEDICAL WASTE: Primary Care Acute Care Skilled Nursing _Transfer Stag gyrator_ Ltd Neu e[ r Sm�ettClinic <br /> ~— Storage (2-10) _�, Storage 01-SO) storage ( 40 } <br /> _ RECREATIONAL HEALTH: Pool/Sps Number of Pools out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP X- Has Mat PPL <br /> Loc Naz Waste <br /> DISC NPL Site RB/H20 4 Other <br /> Other Lead Agency Site Agency: RWOCS <br /> _ SOU D WASTE: Landfill Transfer Sta Recycling Fac Waste Storage fee5tattansry Waste/Exempt <br /> ctor site Sit* <br /> SLI Vehicle No. D�mpater No. � <br /> VECTOR CONTROL: Poultry Farms Mex Number of Birds <br /> Kennel <br /> FACILITY and/or PRO <br /> EMERGENCY NOTIFICATION for this GRAM DAY NIGHT <br /> q ' j y7 �i1 Fr .2C (.z0 y _a� l <br /> CONTACT 1 �C/v" , ty p S"1', ( ) <br /> CONTACT <br /> p.; E- <br /> BILLING <br /> SIGNATED EMPLOYEE 0 LD PROGRAM ELEMENT !! 2�• CURRENT STATUS <br /> a] <br /> F UNITSEPA ID #: 2— INSPECTION CODE :and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or anent 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 an this farm. I also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all appticable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal awe. <br /> APPLICANT'S SIGNATURE <br /> Title: -cl Date: �'� �7 /� <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applies e, 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 JOACUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as <br /> 4 it is available and at the same time it is provided to me or my represwtative. <br /> Fee Amount Amount`Paid� Date of Payment Payment Type Receipt # Check # Recvd By <br /> Gam- 1017 <br /> ' ;ENS —L/ G SUPV —/—J ACCT <br /> I <br />