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GENERAL PROGRAM FILE r New Edit _ (PRbG3) revised 5/21/93 <br /> ' I <br /> fACILITY'ID R / SQ f FACILITY NAME <br /> RECORD ID 0 w `�� PRIOR SWEEPS/COMP / <br /> DAIRYt Grads A Grade's Milk DIRpe"oer Nunber of container* In Multi-Weed Unit , <br /> FOOOt Restaurant Market Ccnmissary Mobile rood Produce Stand Ise Plant <br /> Sestlrq Capacity Sq Ft Market w/Food Prep: Y / W <br /> Tes"rery Food Facility Special Food Event vending Machines Ntvher:of Vending Units , <br /> Food Vehicle Make License A RegIstrattari M . Color. <br /> HAZARDOUS HASTE: •- Tons Generated/Yr TIE' PERMIT Facility 4 CA CE PSR I <br /> HOUSING: Hotel/Motel No. of units Jail/Exempt Institution . Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupsncy ---J / <br /> LiCUID 11ASTEt Purger Vehicle ft.per- Yard Cliemiesl 191100Wo: Package Ts Plant - <br /> MEDICAL WASTE% Primary Care Acute Care Skilled Nursing Lg.Cenerator . Sm Generator i <br /> E. Storage (2-10) Storage (11-SO) Storage (. >50 ) Transfer Ste' Ltd Hauler Yet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Hiner of Pools Out of Service Pool Natural Bathing P1see <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Naz waste Haz Hat PPL <br /> Other Lead Agency Site 'Agency: RUDCB QTSC HPL Site R9/H20 Q Other I <br /> SOLiD WASTE% Landfill Transfer Sts Recycling Fac haste Storage Fac Ag Kaste/Exeapt Site <br /> Y SW Vehicle No Durrpater No. Stationary Cempsctor Site f <br /> S- /� f <br /> I VECTOR CONTROL: Poultry Farm Max Nu bar of Birds Kernel' �1111G k /IC.f! <br /> i <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM . . DAY NIGHT ' <br /> 3 PAYMENT <br /> �- CONTACT 1't (C.t r C' I �f �7 c: i �E/{ l�iC (' ) RE EI i1 1 D <br /> CONTACT 2 : ( ) APR 01 .-_ <br /> DEtIGNATED EMPLOYEE (� PROGRAM ELEMENT f `; CIJRREi 3 <br /> IN 4. <br /> LI <br /> 9 OF UNITS i EPA ID t: ENV! SPECTIflN CC E i" + <br /> 2q: d <br /> BILLING Ord COMPLIANCE ACKNOWLEDGEMENTS it the undersigned owner, operator or agent of same, acknowledge that all site ard/ar t <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the. <br /> ' BELLING PARTY on this form. I *lee e*rtlfy that i 'heve"prepared this application end that the work'to be perfonsed wili be done i <br /> In accordance with all appllcable SAH JOAD(UiIR COUNTY Ordinance Codes and/or Standards aid State and/or Federal taws.` <br /> APPLICANT'S CiGNATURE <br /> Title: �j 1 2zo, Date, — 9 Page 1lIII <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I,' the owner, operator or agent of so 'of .. .' <br /> the property located at the above site addresa hereby authorize the release of any and ail resul b, geotechnical data and/or ,6 <br /> envlrormental/site assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALIH SERVICES ENVIRONMENTAL WEALTH DIVISIOIf as soon as <br /> It is available and at the same toms It Is provided to me or my representative. t <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt M ` Check 0 Rscvd By <br /> r <br /> RENS „�-f 1 sIJPV �/ i. ACCr �J UWIT CL1( / J <br />