SITE INFORMATION AND CORRESPONDENCE

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GENERAL PROGRAM FILE New Change Edit �� (PROG3) revised 5/21/93 FACILITY ID # lJ r� 4 FACILITY NAME 6 V I tt��// (�_, RECORD ID # PRIOR SWEEPS/COMP # I 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 /SITE SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste Haz Mat PPL Other Lead Agency Site I_ Agency: RWQCB _,L DTSC NPL Site RB/H20 Q Other _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site SW Vehicle No. Dumpster No. Stationary Compactor Site o� VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 ( ) ( ) CONTACT 2 n ( ) ( ) DESIGNATED EMPLOYEE # 9 PROGRAM ELEMENT # Z O CURRENT STATUS # OF UNITS EPA ID #: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 # Recvd By REHS _/ / SUPV �/ / ACCT _/ / UNIT CLK _/ /