SITE INFORMATION AND CORRESPONDENCE

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GEUERAI PRnGRAM FILE New _ Change Edit (PROG3) revised 8/26193 FACILITY ID 0 / 7 G C� FACILITY NAGE RECORD 10 0 I�G0 X 77 PRIOR SWEEPS/CCIMP DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand lee Plant Seating Capacity Sq Ft Market w/Food Prep: T / N - Tanporary Food Facility Special Food Even[ Vending Machines Number of Vsndina Unfts Food Vehicle Make License 0 Registration 0 Color HAZARDOUS HASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR _ HOUSING: Hotel/Motel No, of Units Jail/Exempt Institution Housing Abet Employee Housing No. of Enployees Approx Dates of Occupancy _J_� to LIDUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator „s Storage (2-10) _ Storage (11-50) Storage ( "0 ) Transfer Ste Ltd Hauler Vet Clinic RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place y SITE MITIGATION: Environ Assess UST/CAP Loc Hat Waste _y_ Haz Mat PPL Other Lead Agency Site Agency: R%4CB DTSC NPL Site RS/H20 0 Other _ SOLID .CASTE: landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Durtpster No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Birds Kemal EMEP.GE?jCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CC11TACT 1 ( ) ( ) CONTACT 2 ( ) DESIGNATED EMPLOYEE # D6 gC� PROGRAM ELEMENT 0 Z p 5 3 CURRENT STATUS tt OF UNITS EPA ID S: INSPECTION CODE S BILLING and COMIPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of saws, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity Mill be billed to the party Identified as the BILLING PARTY on this form. I also certify that ive pired this application and that the work to be performed will be done irm accordance with all applicablISAIV4' epardinance Codes and/or Standards and State and/or Federal laws. 11�APPLICANT'S SIGNATURE Titte: yff. tprl- �o� �Jfir, Bait) 0�_ �;W-,,A 0/o0-1 Date: ✓ 11 of save of AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator spent the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envirorritental/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 aro or my representative. Fee Amount Amount Paid Date of Payment Paywent Type Receipt 0 Check-f Recvd By moo.= NPV I A UNIT CLK _J_J