SITE INFORMATION AND CORRESPONDENCE

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GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 FACILITY ID-9 FACILITY NAME RECORD ID # PRIOR SWEEPS/COMP # DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant Seating Capacity Sq Ft Market w/Food Prep: Y / N Temporary Food Facility Special Food Event Vending Machines Number of Vending Units Food Vehicle Make License # Registration # Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR _ HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement Employee Housing No. of Employees Approx Dates of Occupancy _/ / to LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) _ Transfer Sta Ltd Hauler _ Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place -LZSITE MITIGATION: Environ Assess �_ UST/CAP Loc Haz Waste Haz Mat PPL Other Lead Agency Site Agency: RWDCB DTSC NPL Site RB/H20 0 Other _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dumpster No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM !� j - ry DAY NIGHT CONTACT 1 Ir 1, WG.�i�ra.. (ILLL.)�SZ" [n9 7 3 CONTACT 2 : lY�.�iClde �'PdIII 1Z�C N-L (�Y) JL- Z(]9D (&E),-9741 ' QuyR DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS # OF UNITS EPA ID #: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that 81l site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billedop,the party identified as the BILLING PARTY on this form. I also certify that I have prepared this application and that the work 4oformed will be done in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Fede i`iaws. APPLICANT'S SIGNATURE , 1� Title: V l �-A)V. k IS le 44,6 , — Date: �C lel 9 6 AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd11 By 06 REHS _/ / SUPV _/ / ACCT / / sI UNIT CLK _/ /