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GENERAL,PROGRAM FILE New Change __ Edit _ (PROG3) revised 5/21/93 <br /> FACILITY IDR FACILITY NAME — -_ - --- <br /> RECORD ID 0 =PRIOR OF <br /> DAIRY: Grede A _ Grade B _ Milk Dlnpemer Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant — Market _ Commissary _ _ Mobile rood _ Produce Stand _ Ice Plant <br /> Seating Capacity Sq Ft Mnrket w/road Prep: T / N <br /> Terporary Food Facility _ Special food Event VeMlmy Machines Nurber of Vending Units <br /> Food Vehicle _ Make Licenso M ---------__ Registretimi s Color <br /> HAZARDOUS WASTE: - Tons Generated/Yr _ TIERED PERMIT facility : CA CE PBR <br /> HOUSING: Hotel/Motel _ No. of Units Jnit/Exeopt Institution Housing Abatement _ <br /> Enployee Housing _ No. of Employees _ Approx Dates of Occupancy _/`/_ to <br /> _ LIQUID WASTE: Pumper Vehicle _ Pumper Yard Chomical Tollets No. _ Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care — Acute Cnre Skilled Nursing Lg Generator Sm Generator _ <br /> Storage (2-10) _ Storage (11-50) _ Storoge ( >50 ) _ Trewsfer Ste Ltd Hauler Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools ___ Out of Service Pool _ Natural Bathing Place _ <br /> _ SITE MITIGATION: Environ Assess -4i USf/CAP _ lac Ilez Wnste Hat Mat PPL <br /> Other Lead Agency Site _ Agency: RWOCR DISC NPL Site _ RB/H2O Q Other _ <br /> _ SOLID WASTE: Landfill _ Transfer Ste a Recycling me Waste Storage Fee — Ag Waste/Exempt Site _ <br /> SW Vehicle No. Oimpster _ No. Stationary Compactor Site _ <br /> VECTOR CONTROL: Poultry Farm _ Max Nmmber of Birds Kennel _ <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT c,,- 'i �_ S . O• C- •� (2L7'I)�1L3_ '3\21 _ 1, <br /> CONTACT 2 : 'CON`! Mk(ri1fJ Kt E/NFCW E2 ( ( ) `r' <br /> DESIGNATED EMPLOYEE 0 -j L� ! PROGRAM ELEMENT 1 r CURRENT STATUS <br /> Y OF UNITS : EPA ID /: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned saner, operator or agent of sone, acknowledge that all site end/or <br /> project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party Identified as the <br /> BILLING PARTY on this form, i also certify that 1 have prepared this application and that the work to be performed will be done <br /> In accordance with all app t SA iJ QUI TY 0 (nance Codes and/or Standards and State end/or Federal laws. <br /> eAPPLICANTS SIGNATURE <br /> �� <br /> (( r <br /> Title: LI(=I/�;�P-Itf�r /V <br /> � ' C- - mate: - �S —Cl�c° Page AOR <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 end/or <br /> environmental/site assessment informatfon 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 Aneun[ Peld Date of PaymentPayment Type Receipt R Check R Recvd By <br /> REHS _ / i / .� SUPV I ACCT - _/ .__/ ',' UNIT CLK <br />