SITE INFORMATION AND CORRESPONDENCE

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SENERAL PROGRAM FILE New Chnnge Edit _ (PROG3) revised 5/21/93 FACILITY ID 0 DD �a 3 FACILITY NAME (nJ � 6J/� �7 `F'OVL lL7tNIA/C RECORD ID 0 if D 5/�a� PRIOR SWEEPS/COMP 0DAiRY: Grade A/ Grade B Milk Dispenser Number of Containers In Multi-Head Unit FOOD: Restaurant Market Cortmlasary _ _ Mobile Food Produce Stand Ice Plant _ Seating Capacity Sq Ft ___ Hnrket w/Food Prep: Y / N Temporary Food Facility Special Food Event __ Vending MAChines Nurber of Vending Units Food Vehicle Make Llcense 0 _ Registratfoii M Color — HAZARDOUS WASTE: Toms Generated/Yr _ TIERED PERMIT Facility : CA CE FUR HOUSING: Hotel/Motel No. of Units Jail/Exempt institution Housing Abatement Employee Housing No, of Employees _ _ Approx Dates of Occupancy _/—/— to — LIOUID WASTE: Pumper Vehicle Pumper Yard _ Chemical Tollets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sm Generator Storage (2-10) _ Storage (11-50) Storoge ( >50 ) _ Tronsfer Stn _ ltd Hauler Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa NtJrher of P00(s _ _ Out of Service Pool Natural Bathing Place _ SITE MITIGATION: Environ Asress UST/CAP Loc Ilaz Wnste Haz Mat PPL Other Lead Agency Site Agency: RWOCB DISC NPL Site RB/1420 0 Other SOLID WASTE: Landfill Transfer Sta s Recyclinq Fnc Wnste Storage rac Ag Waste/Exempt Site SW Vehicle No. Dtxq-K ter No. Stationary Compactor Site VECTOR CONTROL: Poultry form Max Hrartr:r of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 t T `Y\ rt( Yhu,lam ( )-- CONTACT -CONTACT 2 Royq k'1 u YY\its ___F PROGRAM ELEMENT 0 CURRENT STATUS N DEtIGNATED EMPLOYEE �1-) 1 1- OF UNITS EPA 10 0: 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 hnve prepared this application and that the work to be performed will be done In accordance with sit applicabl�OUNTI��rnce Codes end/or Standards end State end/or Federal laws. APPLICANT'S SIGNATURtE Title: 'r'� ;�� ° / ate Date: 5�25�/� Page 1(111 AUTHORIZATION TO RELEASE INFORMATION': In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at tie above sfte address hereby authorize the release of any and all results, geotechnical data and/or environmental/site sssestment 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 Payrrwnt Payrr><vrt Tyfx Receipt 0 Check 0 Recvd By RENS 4 / lq / SUPV __ / /_ ACCf /� / ��l [NiT CLK F —/ /