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GENERAL PROGRAM FILE New 1 chmige Edit (PROG3) revised 5/21/93 <br /> FAC1LIiY- ID-t 5� f /)!1 FACILITY NAME= E< <br /> RECORD ID t ;.5 C� Y�� PRIOR SWEEPS/COMP t1 <br /> DAIRY: Grade A_. Grade 8 Milk Dispenser _. Nunber of Containers In Huttf-Head Unit <br /> _ FOOD: Restaurant _ Market i;. Comslssary _ . Mobtte Food_ Produce Stand Ice Plant pal <br /> <.Seatirq Capaci ty _ Sq Ft Market w/Food Prep: Y ! N <br /> Terporary Food Facility Sped at Food Event Vending Machines MEnber of Vending Units �• <br /> Food Vehicle - Make License 0 - Reglstra t imi Y Color <br /> HAZARDOUS WASTE: Torts Generated/Yr TIERED PERMIT facility - CA CE- FOR <br /> _ HOUSING: Hotet/Motel No.. of Units Jail/Ex"pt Institution Hawing Abetment <br /> Enployee Housing No. of Caployees Approx Dates of Oceurancy _( /_ to <br /> LIQUID WASTE: Pumper Vehicle Pusper Yard Chemical Toilets Mo- - Package Tx Plant <br /> MEDICAL WASTE- Primary Care_ Acute Core Skilled Nursing _ Lg Generator _ Sm.Generator:_ <br /> Storage (it-SO) Storage ( >50 ) _ Transfer Ste ' ltd Hauler Vet Clinic <br /> RECREATIONAL HEALTH* Pool/Spa Nurber of Pools .Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION- Envi ron bsess- J UST/CAP Loc IIaz.Waste <br /> _ Hat Hat PPL <br /> r ^] <br /> Other Lead Agency Site _ Agency: RWOCB DISC_ NPL Site RB/1120 0 Odor <br /> _ SOLID WASTE: Landfill Transfer Ste _a Recycling Fac _ Waste Storage Fee`_ Ag Waste/Exespt—Slte <br /> SW Vehfcta No- Durpa ter No. Stetlonary Compactor SO _C I-� <br /> VECTOR CONTROL.' Poultry Farm_ Max Nurber of 81 role 7zi <br /> -r <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY <br /> r V\ ,1' ✓l"L� owl <br /> CONTACT 1'9- { MA2Z�w1 CK, INF�WER ) ( )g(i8_ 1345 (a) _ZZ�=- R <br /> CONTACT 2 c. """ <br /> DESIGRATEO EMPLOYEE.- PROGRAM ELEMENT t CN(RENT'STATUS <br /> f OF.UNITS t, _I EPA ID 0: INSPECTION CCOE <br /> BILLING and COMPLIANCE ACKMWLEDGEMENT: 1, the undersigned Owner, operator or agent of smahaekr&ledge thatalt site;and/or <br /> project apeefffc PNS/END hourly charges associ ted with this fmcflity or-activity.wilt be,tattled,to:)thaparty ldentlf Fed'as the <br /> BILLING PARTY: Orf thle form.: o.certify hat I have prepared this apptication and that th%work'to be performed-wl Ct„be done In accordarxgirtth.•tl appli abl JOAO N C T Ordi nen odes 'and/or Standards and State and/or Federal IBWS-'rl <br /> APPLICANT'S SIGNATURE <br /> fkC�F.�T C- eANSwLTAIrr-� o 1'(i9 iOIT <br /> Tltte: PV'CVkP�"rt�n7-- K1, Rlt -De%4 GX.01; 6m 11 Date: <br /> AUTHOR IZATIOt;TO,RELEASE. INFORMATION:- In addition to the above,: when applicable, 1, thao-o rk;opermtor oragent of same; of <br /> - the propertylocated at t"e above site.address hereby authorize the release of any and all results..geotechnlca L.data and/or <br /> environsentaUsfte assesaacnt informattom to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL'HEALTH DIVISION as soon as <br /> It is avallableand •t the same time it is provided to me or my representative. <br /> Fee Amount - ` Anxxnt Paid Date of Payment Payment Type Receipt M ` Check s Recvd. .By <br /> -oS• wa, <br /> p r 'Oil <br /> RENS - ! /—�u SUPV _!_!_[ACCT ,r UNIT�CLK _/ /' <br />