SITE INFORMATION AND CORRESPONDENCE

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GENERAL PROGRAM FILE New I/ Chonge Edit (PROG3) revised 5/21/93 FACILITY ID s Sq'�I FACILITY NAME RECORD ID MPRIOR SVF.EPS/COMP A DAIRYs Or" A Grade B Milk Dispenser — Number of Containers in Multi-Head Unit FOOD: Restaurant Market _ Commissary __ Mobile rood _ Produce Stant __ Ice Plant Seating Capacity Sq Ft Market w/rood Prep: Y / 4 Temporary Food facility _ Special Food Event _ Vending Machines _ Number of Vending Units Food Vehicle _ Make License N Reoistratimi M Color HAZARDOUS WASTE: .. Tons Generated/Yr _ TIERED PERMIT Facility : CA _ CE _ PSR — _ HOUSING: Hotel/Motel _ No. of Units Jmil/Exempt Institution Housing Abatemvent _ Employee Housing _ No. of Employees Approx Dates of Occupancy _/_/— to LIQUID WASTE: Pumper Vehicle _ Pu per Yard Chemical Toilets _ No. _ Package Is 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 _ NuFrber of Pools Out of Service Pool _ Natural Bathing Place—Az _ SITE MITIGATION: Environ Assess UST/CAP Loc iiaz Waste — Naz He[ L Other Lead Agency Site ✓_ Agency: RWOCR — Oise _ NPL Site _ RB/1420 0 _ Other — _ SOLID WASTES.Landfill Transfer Ste _ Recycling nae Haste Storage Fac _ Ag Waste/Exelapt Site — SW Vehicle No. Durrpster No. stationary Compactor Site _ VECTOR CONTROL: Poultry Farm _ Max Nuixr of Birds Kernel _ EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 S John Guzman ( 209) 982 - 2090 (—) C04TACT 2 : DESIGNATED EMPLOYEE B a-_. PROGRAM I US 'Z,c a OF UNITS EPA ID 0: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific PNS/EHD 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 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. APPLICANTiS 51GNATURE :6,��N.."e e"�' n Paye 1011Title: Conrrirtnr Date: 9/9/93 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 mvirormental/ante 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 Amowt Amount Paid Date of Poyment payment Type Receipt Al Ch=Recvd a3�f% C ,5 �3 � SUPV _/_/_ ACCT i / 19 /1 UNIT CLK _/_/