SITE INFORMATION AND CORRESPONDENCE

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4PRMOMiLE : New ChangeEdic (PROG3) revised 5/21/93 D 0,C)�3 0 -_ FACILITY NAME T - _It RECORD 10 * bz p 7 N PRIOR SWEEPS/COMP 0 DAiRYs Grade A TTGrade 8 Milk Dispenser Number of Containers in Multi-Head Unit FOOD: Restaurant Market Commissary _— Mobile food Prockrce Stand Ice Plant __— Seating Capacity Sq Ft Market w/Food Prep: Y / N Temporary Food Facility Special Food Event �— Vendi )q Mnchines Nurber of Vending Uri its Food Vehicle Make License. p ; — Regiatratirni q Color _ HAZARDOUS WASTE: Tons Generated/Yr _ TIERED PERMIT Facility CA CE FOR _ HOUSING: Hotel/Motel No. of Units Jai!/Exempt institution Housing Abatement Employee Housing No. of Ertployees Approx Dates of Occupancy _/ / to LiQUID WASTE: Pumper Vehicle Purger 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 Ste Ltd Hauler Vet Clinic RECREATIONAL HEALTH: Pool/Spa Number of Pools — Out of Service Pool Natural Bathing Place —� SITE MITIGATION: Environ Assess X_ UST/CAP -- Loc Haz Waste Haz Mat PPL Other Lead Agency Site Agency: RWQCO DiSC NPL Site RB/H20 Q Other SOLID WASTE: Landfill Transfer Ste Recyclinq Fac Waste Storage Fac AgMwwMOM-F1te SW Vehicle No. Dupa rter No. Stationary�F�p/i VECTOR CONTROL: Poultry Form Max Number of Birds Kennel �, - ---------- - 11 ihF 9 2 1997 EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NiGHT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES CONTACT 1 't Phil Waterford (Ford) (ao-9_) -2-2-- ZG� FNVIFIOfLMENTPk HEALTH DIVISION CONTACT 2 . Martin Ostendorf (91&) 923 - 1097 DEtIGNATED EMPLOYEE N 0 PROGRAM ELEMENT A CURRENT STATUS M OF UMTS EPA ID aY: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: t, the undersigned owner, operator or agent of Same, acknowledge that all site end/or project specific PHS/EHO hourly charges associated with this facility or activity will be bitted to the party identified as the '. BILLING PARTY on this form. I also certify that 1 have prepared this application and that the work to be performed will be done In accordance with all applicable SAN JOAQUiN COUNTY Ordinance Fodes aril/or Standards and State and/or Federal taws. APPLICANT'S SIGNATURE Title: r r'eTee� -�C�d 6� Date., O /c/. - / -7- Page IOB AUTHORIZATION TO RELEASE INFORMATION: to addition to the above, when applicable, 1, the owner, operator or agent of some, of the property loe3ted 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. fr Fee Amount Amount Paid Date of Pnyment Payment Type Recelpt 0 Check 0 Recvd By Jx2A I SUPV _/ _ / IACCT �/O�3 / g7 UNIT CLK r