SITE INFORMATION AND CORRESPONDENCE

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GENEB.AL PROGRAM FILE New 0 Charge Edit • (PROG3) revised 8/26/93 FACILITY ID g �` /_ �/�� FACILITY NAME RECORD TO 0 .C�' ��v!"�� PRIOR SWEEPS/CQ1P Y _ DAIRY: Grade A Grade B _ Milk Dispenser Nunber of Containers in Nulti-Hesd Unit F00D: Restaurant Market _ Commissary _ Mobile Food _ Produce Stand _ Ice Plant Seating Capacity Sci Ft Market w/Food Prep: y / N Temporary Food Facility _ Special Food Event _ Vending Machines _ M of Vending Unita; Food Vehicle Make License g Registration / Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ PER HOUSING. Hotel/Motel No, of Units Jail/Exempt Institution Housing Abatement Employee Housing _ No. of Employees Approx Dates of Occupancy ..J____/_ to LIQUID WASTE: Punper 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 (11-90) _ Sterag• < .90 ) _ Transfer Ste _ Ltd Hauler — Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa _ Number of Pools Out of Service Pool _ Natural Bathing Place SITE MITIGATION: Environ Assess UST/CAP _ Loc Hai Waste _ Hai Mat PPL _ Other Lead Agency Site Agency: R%RCB L,-- OTSC _ NPL Site RB/1120 Q _ Other SOLID WASTE: Landfill Transfer Sta Recycling Pae Waste Storage Fac _ Ag Waste/Exempt Site SW Vehicle _ No. Dumpster _ No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kervst EMFP.GENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 : CONTACT 2 : DESIGNATED EMPLOYEE N L/, _ PROGRAM ELEMENT g CURRENT STATUS M OF UNITS : EPA ID X: INSPECTION CODE > C L- BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, acknowledge that all site and/or project specific PNS/EHO 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 wilt be done In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE I Title: Date- AUTHCRIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, of the property located at the above site address hereby authorize the release of any end ell results, geotechnical date and/or environmental/site assessment information to SAN JOAOUIM COUNTY PUBLIC HEALTH SERVICES ENVIROMIKENTAL HEALTH DIVISICN 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 A Check 0 Recvd BY RENS _/ /_ SU" � / J� ACCT ��_-_ UNIT CLK n