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GENERAL PROGRAM FILE : New Change Edit (PROG3) revised 5/21/93 <br /> I <br /> FACILITY 10 0 FACILITY NAME <br /> RECORD iD / PRIOR SWEEPS/COMP A i <br /> DAIRYS Grads A Grade s Milk Dispenser Nuiber of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> I <br /> seating Capacity Sq Ft Market w/food Prep: Y / H <br /> Temporary Food Feeilfty Special Food Event Vending Machines Number'*( Vending Units <br /> Food Vehicle Make License N Registratiori 0 Color <br /> HAZARDOUS WASTE: Tons Generated/Tr -TIERED PERMIT Facility CA CE POR <br /> _ HOUSINGI Hatel/Hotel No. of Units Jail/Exeapt institution Housing Abatement <br /> Employee Housfng No. of Employees Ar-prox Dates of Occupancy .. 1 to <br /> LIQUID WASTES Pumper Vehlete Pumper Yard 'Chemical Toilets" " No. Package Tx Plant" - <br /> MEDICAL WASTE: Prfinery Care Acute Care Skilled Nursing " Lg Generator . Se Generator - <br /> Storage (2-10) Storage (11-50) Storage G 3,50 ) Tr"fer Sta Ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH: Poot/spa Humber of Pools Out of Service Pool Natural Bathing Place <br /> S1 TE MITIGATION: Enviren AssessUST/CAP Loc Hoz Waste Naz Mat PPL <br /> other Lead Agency Site Agency: RWOCB DiSC NPL Site RB/H20 O Other <br /> SOLID WASTE: Landfill Transfer Ste Recycling Fee Waste Storage Fac Ag haste/Exempt Site <br /> SW Vehicle No.. Dum ter No. Stationary Cenpector Site <br /> VECIOR CONTROLS Poultry Firm Max Neer of Birds Kennel 1]G kVgni /lG�—• " <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM" DAY NIGHTPAYMENT <br /> ' <br /> CONTACT 1'SSl� ►Q lG it �} /�] i7 U ! /� iI c C'" L��7 . <br /> CONTACT 2 0( —' <br /> DOIGNAYED EMPLOYES 0 PROGRAM ELEMENT1211 pRjflil� 1N <br /> i- ATH 5EF2VlCES: <br /> 0 OF UNITS a EPA lO 0: ENVI SPECTION CODE 1 `�' <br /> BILLING and COMPLIANCE ACIUlOWLEDGEMENTn 1, the "undersigned owner, operator or agent of some, acknowledge that ail site and/or <br /> project specific PHS%EHD hourly Charges associated with this facility or activity will be bitted to tate 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 perfonoed will be done <br /> In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards"and State and/or Federat laws. ' <br /> APPLICANT'S M CNATURE s_ <br /> ' Title: Il W 7 Date-wr1'1.tlRe 101i . <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the.o►ner, operator or agent of saw,-of <br /> the property`located at the above site address hereby authorize the release of any and ail results, geotechnicat date and/or <br /> envirornientat/site assessment informration 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 Psld Date of Payment Payment Type Receipt A Check !- ReCvd By <br /> RENS __ I - _ / SUPY �/ l IILCT lnflT a>< <br />