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GENERAL PROGRAM FILE New _ Change Edit (PROG3) revised 8/26193 <br /> i FACILITY ID S '05 -3 /� FACILITY NAME <br /> n (J�l <br /> RECORD 10 S (f� i/f PRIOR SWEEPS/COMP S <br /> _ DAIRY: Grade A /Grade B Milk Dispenser Number of Containers in Multi-Head Unit U 0 <br /> _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y / N <br /> Tgrvorary Food Facility Special Food Event Vending Machines Number of Vsndins Unita <br /> Food Vehicle Make License S Registration S 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 /> Employee Housing No. of Employees Approx Dates of Occupancy _J_____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 Sm Generator <br /> Storage (2-10) _ Storage (11-50) _ storage ( %90 ) _ Transfer ata _ Ltd Hauler Vet 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 L/' Haz Mat PPL <br /> Other Lead Agency Site Agency: RWOCB DTSC NPL Site RB/H2O g Other <br /> _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster No. StationaryGS1ift <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennet <br /> 1 <br /> EMF9GF?1CY NOTIFICATION for this FACILITY and/or PROGRAM DAY <br /> y� SAN JOACUIN COUNTt' <br /> CONTACT t / I ,��r:.�.^:— hl(�+- �. c )�3�-- """CCHFA' EEfs- <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE N1 PROGRAM PROGRAM ELEMENT I Q 5,9 CURRENT STATUS <br /> 0 OF UNiTS I EPA ID S: 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 application and that the work to be performed will be done <br /> in accordance with all applicable SAN JOAQUiN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date* <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of $mime, 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 of soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Fee Amountt Paid Date of Payment Payment Type Receipt / Check 0 Recvd By <br /> OP <br /> REHS F-/ 1 SUPV _/� ACCT' /_J�,._ UNiT CLK _J_I <br />