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' `GENERAL PROGRAM FILE New Change E4 it (PROG3) revised 5/21/93 <br /> FACILITY ID # FACILITY NAME S f� <br /> RECORD ID # �f"} PRIOR SWEEPS/COMP # <br /> _ DAIRY: Grade A Grade 8 Milk Dispenser Ntimbeq of Containers in Multi-Heed Unit <br /> i <br /> FOOD: Restaurant Market Commissary XoI Le Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Marketlllw/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event Verging Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: -- Tons Generated/Yr TIEt D PERMIT Facility CA CE PSR <br /> HOUSING: Hotet/Motel No. of Units Jail/E empt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Da es of Occupancy _ /_� to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Tditets No. 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 Hauter _ Vet Clinic <br /> RECREATIONAL HEALTH: Poot/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess—L UST/CAP Loc Raz W to Haz Mat PPL <br /> I <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RS/H20 0 Other <br /> SOLID WASTE: Landfill Transfer Sia Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> �. SW Vehicle No. Dtmpster Fo. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of BirdsKernel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAT NIGHT <br /> CONTACT I c 2 1 S11*(((CQ„ ( ) ( ) <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE # 1 CI PROGRAM ELEMENT # CURRENT STATUS <br /> �.r� <br /> # OF UNITS : EPA 10 #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/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 I have prepared this ippLication and that the work to be performed wilt be done <br /> in accordance with all appLicable SAN JOAQUIN COUNTY Ordinance Codes /or Standards and State and/or Federal laws. <br /> �APPLLCANT'S SIGNATURE <br /> Title: �tJ—(5 Date' <br /> Page lOB <br /> AUTHOR17ATION TO RELEASE INFORMATION: In addition to the above, when i:ticabte, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the re se of any and all results, geotechnical data and/or <br /> envirormentaL/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 repr tative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check Al Recvd By <br /> UNIT C <br /> RENS �� SUP@e /_,-___J ACCT �f I LK �� <br />