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GENERAL PROGRAM FILE New _ Change Edit (PROG3) revised 8/26/91 <br /> i FACILITY IO M _ �? FACILITY NAME <br /> RECORD ID L �(z�Da�.53 PRIOR SWEEPS/CCMP S <br /> DAIRY: Grade A Grade-is 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 <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending units <br /> Food vehicle Make License 0 Registration K Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> _ HOUSING: Hotel/Motel No. of Units Jsil/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) _ storage ( "0 ) _ Transfer ata _ Ltd Hauter _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> _ SITE MITIGATION: Environ Assess V UST/CAP Loc Haz Waste Haz Mat PPL <br /> Other Lead Agency Site Agency: RWOCB DTSC NPL Site RB/1120 g Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac 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 Kennal <br /> EMFPGP!ICY NOTIFICATION for this FACILITY and/or PROGRAM DAY '1 NIGHT <br /> CONTACT 1 �aY IS�fU✓10(✓ (Z'�i ) 535 `A7i4 t ) <br /> CONTACT 2 31K (201) Ei 7iS�Z <br /> DESIGNATED EMPLOYEE N PROGRAM ELEMENT S c, CURRENT STATUS <br /> 1 <br /> 0 OF UNITS : EPA ID 0: 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 will be done <br /> in accordance with alt applicable SAN JOAQUIN C TY Ordinance Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: �WwfIC�.�G �G�K. Date: /- -7 — <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 JOAQUIN 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 ay representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check S Recvd By <br /> REHS !�(i / /� /� SUPV /_J ACCT /_� - UNIT CLK _J_I <br />