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f <br /> -- <br /> GENERAL PROGRAM FILE New Chnnqe Edit (PR vised 5/21/93 <br /> FACILITY ID R ��� FACILITY NAME FEB 18 1997 <br /> RECORD ID 0 15D ��-. PRIOR SWEEPS/COMP N PU�ZJRQN EN IAL HEALTH <br /> _ DAIRY: Grade A Grade 8 Milk Dispenser Ntrrber of Containers in Mu(t -Head Unit <br /> FOOD: Restaurant Market Commissary _ Mobile Food Produce Stand ice Plant <br /> Seating Capacity Sq Ft `_ .—_ Mnrket w/Food Prep: Y / N <br /> Temporary Food Facility Special Food Event Vending Mnchlnes Nurber of Vending Units <br /> Food Vehicle Make License N Registratiori N Color <br /> HAZARDOUS WASTE: - Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of Units Jnil/Exempt Institution Housing Abatement <br /> Eaployee Housing No. of Employees _ Apprnx Dates of Occupancy _/—/— to <br /> — LIOUID WASTE: Pumper Vehicle Purper Yard _- chrmical Toilets _^ No. _ Pnckage Tx Plant <br /> — MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator <br /> Storage (2-10) _ Storage (11-SO) Stornge ( >50 ) _ Transfer Stn Ltd Hauler Vet Clinic _ <br /> RECREATIONAL HEALTH: Poo VSpa Ntmber of Pnols ___^ Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess x UST/CAP ------ Loc Haz Waste Haz Met PPL <br /> Other Lead Agency Site Agency., RWDCR ____ DiSC HPL Site RB/H20 0 Other <br /> _ SOLiD WASTE: Landfill Transfer Sts _ Recyclinq me Wnste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. — Dtmpcter ___ No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Form Max NrmtK!r of Birds _ Kernel <br /> EMERGENCY NOTIFICATION for //this FACILITY end/or PROGRAM 7DAY NIGHT <br /> CONTACT 1 t I [i K (i« C! --- -- -- (Wo -Li-1-� 1 ( ) <br /> CONTACT 2 S.c� �/� �'IU�tc'� (?�n)� `l II ( ) <br /> DESIGNATED EMPLOYEE Al (p 0 PROGRAM ELEMENT I2� d CURRENT STATUS <br /> N OF UNITS EPA ID N: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that 01 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 s:so certify that i hnve prep ed is application and that the work to be performed will be done <br /> In accordance with at applicabl JOA Y Or �4s and/or Standards and State and/or Fr6la�s y9 <br /> iHi�iuAUUIN COUNTY <br /> APPLICANT'S SIGNATURE �` <br /> C!ti <br /> Crc� Date-!O f '1 �y— / MENTAL HEALT4 <br /> _95,qv <br /> Title• J�0j; <br /> AUTHORIZATION TO RELEASE INFO TION. In ddtin to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the �rQ3erty (oc_tLN.d at the 3ixz:° s{te address hereby authorize the release of any and all results, geotechnical date and/or <br /> envirorri:entaiiai:a otsessment information to SAN JOACUIN 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 Pa Date of Payrnent Vaynx:rlt type Receipt N check N Recvd By <br /> RENS 02e/_ZLJ / SUPV _/`_ / __ ACCT / /CAI UNIT CLK —/ / <br />