SITE INFORMATION AND CORRESPONDENCE

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GENERAL PROGRAM FiLE : New chm,ge Edit _ (PROG3) revised 5/21/93' FACILITY ID 0 FACILIfr NAME RECORD ID 0 PRIOR swur5/COMP N DAIRY: Grade A Grade B Milk Dispenser Ntrriber of Containers In Multi-Head Unit TOGO: Restaurant Market romnlasnry _ Mobile rood __ Prrx w,,e Strand lee Pinnt —_ Seating Capacity Sq rt — _ M,nrket w/Toon tier: Y / N Teuporary Food Facility Special Food Event __ _ Verxiing Mnchlnes HLs ,-r of Vending Units Food Vehicle Make Lfcenee N Registratfai 0 Color HAZARDOUS WASTE: Tons Geriereted/Yr TIERED PE.R111T rncllity CA CE PBR _ HOUSING: Hotel/Hotel NO. of Unita Jail/Exeupt Institution Housing Abatement Employee Housing No. of Enployees Approx Dntes,of Occupancy _/ / to { Y_ LIOUID WASTE: Purser Vehicle Ptnper Yarn Cl,pmicnl Toilets _ No. Package Tx Plant MEDICAL WASTE: Primary Care Acute Care Wiled Nursing LU Generator Sm Generator Storage (2-10) ___„_ Storage (11-50) Stornge ( >50 ) Trnn4fer Stn Ltd Hauler Vet clinic RECREATIONAL HEALTH: Pool/Spa HLmber of fools Out of Service Pool Natural Bathing Place SITE MITIGATION: Environ Assess USr/CAP —_ y . Loc Haz Waste,_ Her Hat PPL Other Lead Agency Site Agency: RWarn Disc HPL Site RB/H20 0 Other _ SOLID WASTE: Landfill Trnnafer Stn Recycling rnr ____ Waste storage roc Ag Wtste/Exeunt Site SW Vehicle No. Drmpater No, Stationary Compactor Site _ VECTOR CONTROL: Poultry Form Mnx Hrirtil-.r of 61rds _ Kenrv.I EMERGENCY NOTIFICATION for this FACILITY arid/or PROGRAM DAY NIGHT CONTACT 1 't " ' l^ + 71c/ )y72- _ S<ltf�1 (21-1 CONTACT 2 , c• ! rity DESIGNATED EMPLOYEE PROGRAM ELEMENT N 2g�Q CURRENT STATUS 3 J f !! OF UNITS EPA ID #: —��------ INSPECTION CODE � BILLING end COMPLIARCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, ackriowtedge that all site and/or project specific PHS/EHO hourly charges associated with this facility or activity wilt be billed to the party identified as the BILLING PARTY on this form. 1 also certify that I have prepared this application and that the work to be performed will be done In accordance with all applicable SAN JCAGUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal taws. APPLICANT'S SIGNATURE �,A ".- Title: �r.0 � 10 yl C, - Date: 1'n��(' 1(11; AUTHORIZATION TO RELEASE INFOPPWt ION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of the prq-�erty icernfi-d at t~e sbcv7 site n6dr_ss hereby iuth(,r17.e the release of any end all results, geotechnical data and/or envirormentol/site assessment Information to SAN JUAOUIN COUNTY PUBLTC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon a§ It is avallabia and at the same time It Is provided to me or my representative. Fee Amount Amount Paid Data of Payment Payment Type Receipt 0 Check R Recvd By Ir ACCT /��_! UNITCLK _/ /