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v <br /> =:cHERAL PROGRAM FILZ New Change Edit (FROG3) revised 8/2603 <br /> FACILITY ID # �� FACILITY NAME .S`m S J d 4z wig/ �&-ti^-4 <br /> RECORD ID # �/��j �� 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 <br /> Temporary Food Facility _ Special Food Event Vending Machines Number of Vending Unita <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotet/Motel No. of Units Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy _J_/ 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 Ste Generator <br /> Storage (2-10) _ Storage (11-50) _ storage ( "o _ Transfer Ste _ Ltd Hauler _ Vet Clinic _ <br /> _ RECREATIONAL HEALTH: Pool/Spe Number of Pools Out of Service Pool Natural Bathing Place <br /> _ SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Hai Mat PPL <br /> Other Lead Agency Site Agency: RWOCB DTSC NPL Site RB/H20 0 Other <br /> CO3vs <br /> ya4,�� <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac -X- 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 q DAY NIGHT <br /> CONTACT 1 : Lai" 99 38`145 <br /> CONTACT 2 : <br /> DESIGNATED EMPLOYEE # S-G PROGRAM ELEMENT 0 �`/ y3 CURRENT STATUS <br /> 0 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 /> 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 application and that the work to be performed wilt be done <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Code/sand/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> i <br /> Title: 4 Date: <br /> AUTHORIZATION 11 TO RELEASE i ORMATION: In addition to the above, when applicable, I, the owner, operator or agent of seise, 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 ENVIROIMENTAL 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 0 Check 0 Recvd By <br /> RENS /_� SUPV _/_J ACCT t"ZI 'Z:�/Z— UNIT CLK _J_f <br />