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GENERAL PROGRAM FILE New Chnnge Edit <br /> _ (PROG3) revised 5/21/93 <br /> FACILITY ID R FACT LI TT HAMS <br /> RECORD ID M PRIOR SWEEPS/COMP 0 <br /> _ DAIRY: Grade A _ Grade R Milk Dispenser _ Number of Conta hers in Mu(tl-Heed Unit <br /> FOOD: Restaurant _ Market COmnissmy Mobile Food Produce Stand Ice Plant _ <br /> Seating Capacity Sq Ft _ _ Market w/rood Prep: Y / N <br /> Temporary Food Facility _ Special Food Event Verx)Ing Mnchines _ Number of Vending Units <br /> Food Vehicle _ Make Llcensr N _ _ _ Registratiomi M Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT real Uty : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of (hilts Jni(/Exempt Institution Housing Abatement <br /> Employee Housing _ No. of Employees Approx Dates of Occupancy _/ /_ to __J — <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chanical Toilets No. Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator _ Sm Generator _ <br /> Storage (2.10) _ Storage (11-50) _ Storage ( >50 ) _ Traefer Stn _ Ltd Hauler _ Vet Clinic _ <br /> -_ RECREATIONAL HEALTH: Pool/Spa Number of Pools ___ Out of Service Pool _ Natural Bathing Place <br /> SITE MITIGATION: Environ Assess J UST/CAP Loc Haz Waste Hez Met PPL <br /> Other Lead Agency Site _ Agerxy: RWOCR DISC NPL Site _ RB/H2O 0 _ Other <br /> SOLID WASTE: Landfill Transfer Ste a Reeyelinq Inc Waste Storage rec _ Ag Waste/Exempt-Site <br /> SW Vehicle No. _ DIN"ter No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Form _ Max Number of Birds Kernel <br /> r-) <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY I Nit - <br /> \ v AQ - otost <br /> CONTACT T t bW M+a2�1e1 �K�<)t�F�WeR ) _ (2a )�$_ 13V 5 ( 01)901 MW= PAt>E2 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE R PROGRAM ELEMENT ! CURRENT STATUS <br /> M OF UNITS : EPA ID I: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNWLEDGEMENT: 1, the undersigned owner, operator or agent of aeme, acknowledge that all site and/or <br /> project specific PNS/END hourly chargee essocI ted with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form, o certify ha[ 1 hove prepared this application and that the work to be performed will be done <br /> In accordance with ell app abl 5 JOAO N C T Ordinen odes end/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title:�F1TFFP"Q_T0N SuK 1 R1L,� ABV 6LL7 -meti Date: Il <br /> Page 101; <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the propertyl ocated at tie 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 /> it is available and at the same time it Is provided to me or my representative. <br /> Fee Amant Art+ant Peld Date of Payment Payment Type Receipt M Check R Recvd By <br /> m <br /> REHS /_i_ SUPV __/ _ - _/__ __ IACC( <br />