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I V(Z <br /> �f SIS ose-en���,��t. <br /> /W— �-s if (,&AtC1140 <br /> CPROG3) revised 5/1g/'�3 <br /> GENERAL PROGRAM FILE New Change - Edit _ S <br /> FACILITY ID # dOD2'7 2 'FACILITY NAME �n/t,EOE,.✓v£NT l7tSOOSC �,�.�-°�ce� <br /> ' RECORD 10 # PRIOR SWEEPS/�P S <br /> /�� �f <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 Prep: Y / N Number of Vending4achines <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motet No. of Units Jail/Exempt Institution <br /> Employee Housing No. of Employees Approx Dates of Occupancy to <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. ___ Package Tx Plant <br /> _MEDICAL WASTE: Primary Care Acute Care Skilled Nursing L9 Generator Sm Generator <br /> Storage (2-10) _ Storage (11-50) Storage C >50 ) __ Transfer Sts _ Ltd Hauler _ Yet 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: RWCCB DTSC NPL Site RB/H20 D Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle ✓ No. _1.L_�— Duapster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kemal <br /> 'NIGHT <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY <br /> CONTACT 1 . ( ) C ) <br /> CONTACT 2 : ( ) ( 7 <br /> DESIGNATED EMPLOYEE # 3` ` PROG; 2-3 CURRENT STATUS <br /> # OF UNITS . EPA ID #: 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 /> JOAGUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <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 JOAOUIN 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 <br /> Paid Date of Payment Payment Type Receipt # Check # Recvd BY <br /> �0-ate >o � 1p� �c*-� �'' -71 <br /> .2 <br /> REHS 4� o�`� / `3 SUPV <br /> '` UNIT CLX �/_ <br />