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GENEPAL. PROGRAM FILE New , Change \'I-- _ Edit • (PitW) revised 8/26/93 <br /> t <br /> �M <br /> FACILITY ID # lD FACILITY NAME $` <br /> 3?DG _r0N ScAval'tag-2�5 <br /> RECORD ID # PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity sq Ft Market w/Food Preps Y / N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Frployee Housing No. of Employees Approx Dates of Occupancy _ / r to <br /> LIQUID WASTE: Pumper Vehicle pumper Yard Chemical 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 } _ Transfer Ste _ Ltd Hauler _ Vet Clinic _ <br /> ..rte 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: RWQCB DTSC NPL Site RB/H20 Q Other <br /> SOLID WASTE: Landfill Transfer Sta V Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> 'EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 : CARLO MARIANI ( 209) 946 -5721 (-ZU)474 - 460 <br /> CONTACT 2 : DAVID IANNI (209 ) 946 -5721 (2—U)3 3 4 - 6068 <br /> DESIGNATED EMPLOYEE it Q �� PROGRAM ELEMENT # CURRENT STATUS <br /> # OF UNITS EPA ID #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> prnject specific PHS/END 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 I have prepared this application and that the work to be performed Nill be done <br /> in accordance with all applicable S IN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE ✓' <br /> itl=;_ASSISTANT GENERAL MANAGER 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 N Check # Recvd N <br /> 20.00 <br /> SUPV _/_ J ACCT I / / UNIT CLK _/�_/ <br />