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GENERA!,.PROGRAM FILE New X Change Edit <br /> (PROG3) revised 5/18/93 <br /> FACILITY ID # -FACILITY NAME <br /> RECORD IO # PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Mutti-Head Unit <br /> _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N Number of VendingeMachines <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr _ TIERED PERMIT Facility : CA CE PSR <br /> HOUSING: Hotel/Motel No, of Units Jait/Exempt Institution <br /> Employee Housing No. of Employees Approx Dates of Occupancy _/_/ to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toitets MO- ____ Package Tx Plant <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing LS Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) _ Transfer Sta Ltd Hauler _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> _ SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQC8 DTSC NPL Site RB/H20 Q Other <br /> ,CIA yWOO <br /> SOLID WASTE: Landfill L Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor Site <br />#ia _ VECTOR CONTROL: Poultry Farm Max Number of girds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 t<�L3L�iCT� f` ','e►" C <br /> CONTACT 2 C ) ( ) <br /> DESIGNATED EMPLOYEE # Ua PROGRAM ELEMENT # vq�.3 a CURRENT STATUS <br /> # OF UNITS EPA IO #: INSPECTION CODE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 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 Amount Amount Paid Date of Payment Payment Type Receipt # Check # Reevd BY <br /> SuPV / " / ACCT / UNIT CLK _f�J <br />