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i <br /> GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID 0 FACILITY NAME <br /> RECORD ID 0 PRIOR SWEEPS/COMP N <br /> _ DAiRY: Grade A Grade a Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ FOOD: Restaurant Market Commissary __ Mobile rood Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/food Prep: Y / N <br /> Temporary Food Facility Special Food Event Vendfrg Mnchines Number of Vending Units <br /> Food Vehicle Make Licence N Registratiori N 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 !/ / to <br /> _ LIOUiD 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) Storoge ( >50 ) ^_ Tronsfer Sta Ltd Hauler Vet Clinic _ <br /> RECREATIONAL HEALTH: Pool/Spa Nlmtwr of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess X usT/CAP Loc Haz Waste Naz Mat PPL <br /> Other Lead Agency Site Agency: RWOCR DISC NPL Site RB/1120 0 Other <br /> SOLiD WASTE: Landfill Transfer Sts ___ Recycling FnC Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dix"ter __ No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Form Max NLmber of Birds KenneI <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 ( ) <br /> DEtIGNATED EMPLOYEE i 7 PROGRAM ELEMENT 0 2��3 :�[CRRENT STATUS <br /> vwcmpzz� <br /> N OF UNITS EPA ID 0: 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 aud that the work to be performed will be done <br /> In accordance with all applicable SAN JOAOUIN COUNTY Ordinance Codes end/or Standards and State/and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Page 100 <br /> Title• Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property 4oeated at ':ie abcvv site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environrental/si:n:• stsessment 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 Amault Amount Paid Date of Payment Paymerit Type Receipt if Check 0 Recvd By <br /> x/77 �/77 7 ro y;77v ; J <br /> RENS _/ / SUPV _/_�_/ � ACCi` �/ �� / /S UNIT CLK _/ / <br />