SITE INFORMATION AND CORRESPONDENCE

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GENERAL PROGRAM FiLE : New _ Change Edit (PRO03)`revised 5/21/93 FACILITY ID N FACILITY RECORD ID 0 PRIOR SWFEPS/COHP N DAIRYt Grads A Orode B Milk Dlrepenser Nurber of Contolners in Muttl-Need Unit FOOD: Restaurant Market tonnl+snry ; Mobile Food Produce StarA Ice Plant Seatlrm Capacity Sq Ft Market Wood Prep! Y / N ' Temporary Food Facility Special rood Event � Vendinq Mnchines __ — Number of Vending Unita Food Vehicle Make Liccrse N Reglstratlari N Color HAZARDOUS WASTES • Tons Genersted/Yr TIERED PERMIT Facility CA CE PBR —� HOUSING: Hotel/Motel No. of Wits Jnil/Exempt Institution Housing Abatement Enployee Housing No. of Errployeet _ — Apprnx Dates of Occupancy � / / to >- / LIQUID WASTES Pumper Vehicle Pumper Ynrd _ Chnmlcal Toilets No. Package Tx Plant MEDICAL WASTEt Primary Care Acute Core Skilled Nursing Lg Generator Sm Generator Storage (2.10) _ Storage (11-50) _ — Storage ( >50 ) Trorinfer Stn Ltd Hauler Vet Clinic RECREATIONAL HEALTH: Pool/Spa Nurher of Pools --- Out of Service Pool Natural Bathing Place XSITE MITiGATIONi Environ Assess UST/CAP lac IioL Waste Nez Het PPL Other Lead Agency Site Agentyd' AWQ CR �� DISC NPL Site RB/1120 Q Other SOLiD WASTE: Landfill Transfer Sto a Recycling roc ___ Wnste Storage roc Ag Waste/Exempt Site SU Vehicle No. Chi"ter No. Stationary Compactor Site VECTOR CONTROL! Poultry Farm Max Nuntr_r of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT t't CONTACT 2 DESIGNATED EMPLOYER M PRUGRAM ELEMENT N CURRENT STATUS N OF UNITS i EPA ID N: INSPECTION CODE v1111.1.1110 ere/ CWLtANCE''ACKNOWLEDGEMENt,t 1, the undefslgnedowner, operator or agent of aamot", ecknowlAedge that tall site and/or project specific PHS/END hourly chargee ess'ociated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. i also certify that I hove prepared this application and that the work to be performed will be done In accordance with all applicable SAN JOAOUIN COUNTY Ordinance Codes end/or Standards and State end/or Federal laws. r �. APPLICANT'S SIGNATURE s Tlcte: " 2ai3 `prt` tTtlnc �� SJit� ./�, / T Page 1011 Dates AUTHORIZATION TO RELE0E 1001114ATIONi in addition to the above, when applicable, t, the owner, operstor or agent of same, of the property'locatsd at the above site address hereby authorise the release of any end all results, geotechnlesl'dats and/or envfronmentat/site assessment 'information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It it available and at the tame time It is provided to me or my representative. Fee Amount Amount Paid Date of Payment— Payment Type Receipt N Check N Recvd By / l / / RE11S ACCP UNIT CLK I —_ _/ I __�