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GENERAL PROGRAM FILE New Change Edit�_ (PROG3) revised 5121/93 <br /> FACILITY ID # FACILITY NAME <br /> RECORD IO # PRIOR ' <br /> DAIRY: Grade A B 91 Lk Dispenser ` of Containers in MuLti-Read Unit <br /> FOOD: Restaurant t Commissary to Food Produce Stant! Ice Plant <br /> Seating Capacity S4 Ft Market w/Food.Prep: Y / N <br /> Temporary Food Facility Special Food Event Voiding Machines Number of Vending Units <br /> Food Vehicle License # Registration # Color <br /> HAZARDOUS WASTE: Tons GeneratedfYr TIUM PERMIT Facility r CA CE PBR <br /> HOUSING: Notat/Notel No. of units Jait Institution Housing>Abat <br /> Employee"Horsing No. of Employees Approx Data&of OCCUPINFICY ,J ! to <br /> LIQUID WASTE:- pumW Vehicle Pumper Yard Chodcat Toilets No. Package Tx Plant <br /> MEDICAL WASTE: Primary Care Acute CareSkilled nursing Lg Generator Sm Generator <br /> storage (2-10) _, Storage (11-50) _ Storage ( ) Transfer Ste d Nauler Yat Clinic <br /> RECREATIONAL HEALTH: Poot/Spa Number of POOLS Cut of Service Pool Natural Bathing Place_ <br /> SITE MITIGATION: Environ UST/CAP L Haz to Haz Mat PPL <br /> Other Lead Agency Site Agency: RW2CB DTSC NPC Site RB/= C Other <br /> SOLID WASTE: Landfill Transfer$to Recycling Foe Waste'storage Fac Ag Waste/Exempt Waste/ExemptSite <br /> SW Vehicle No. Dumpater No. Stationary Conipactor'Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Bi l <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT" <br /> CONTACT 1 { ) C ) <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE# PROGRA14 i # STATUS <br /> # OF UNITS. : EPA 10 ft INSPECTION CODE : <br /> BILLING and COMPLIANCE E0 « I, the undersigned Owner, operator or agent of saw, acknowtedge that all site and/or <br /> project specific'PHS/EHO hourly charges associated with this faef Lity or activity will be bitted to the partr identified as the <br /> BILLING PARTY on this form. I also certify that I. have prepared this-application and that tho.work to be performed will be done <br /> in accordance with all applicable SAN JCMIN CMKff Ordfnwm Codes mWor standards and State xWor Federal Laws- <br /> APPLICANTISSIGHATURE <br /> Title Date:----------------------- <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when appticabLo, I, the owner, operator or,agent of simmov of <br /> the property Located at the above site address.h i the release of any and all results, geetechnicaL'data and/or <br /> envi at/site assessment infonutim.to So JOMIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as-30011 as <br /> it is available and at the saw time it is provided to me or my representative. <br /> Fee Amount Amotmt Paid Date of Payment Payment Type Receipt# check # Recvd <br /> By <br /> REHS UNIT CLK <br />