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`GENERAL PROGRAM FILE New Change X Edit • (PROf3) revised 8/26/71 <br /> FACILITY IO # FACILITY NAME Alden Park / City of Tracy <br /> RECCRD ID # ,� ,j PRIOR SWEEPS/CCMP # -- <br /> DAIRY: Grade A Grade B _ Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ FOOD: Restaurant Market _ Commissary _ Mobile Food _ Produce stand _ ice Plant _ <br /> Seating Capacity Sq Ft Market w/Food Prep: T / H <br /> Temporary Food Facility _ Spec jet Food Event _ Vending Machines _ Number of Vending Uhles <br /> Food Vehicle Make License # Registration N Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ PBR <br /> _ HOUSING: Hotel/Motel _ No. of Units Jail/Exmpt Institution Mousing Abatement <br /> Emmloyee Housing _ No. of Employees Approx Dates of Occupancy J_�_ to _/----J_ <br /> LIQUID WASTE: Pumper Vehicle Pumper Yard _ Chemical Toilets _ No. Package TX Plant _ <br /> _ MEDICAL WASTE: Primary Care Acute Care _ Skilled Nursing _ Lg Generator _ As Generator _ <br /> Storage (2-10) _ Storage (11.50) _ storage ( 180 ) _ Transfer Sta _ Ltd Neuter _ Vet Clinic <br /> RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool _ Natural Bathing Place <br /> X SITE MITIGATION: Environ Assess UST/CAP Loc Naz Waste _ Net Mat PPL _ <br /> Other Lead Agency Site X Agency: RWOCB X DTSC NPL Site _ RB/H2O g _ Other <br /> _ SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste storage Fee Ag W 4e��jie�mpt <br /> SW Vehicle No. Dempster No. Stationary Comh�dlcjo <br /> VECTOR CONTROL: Poultry Farm _ Max Number of Birds Kernel <br /> EMF?CENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY MIGHT <br /> �ih�nirdlEN6AL HF4:- <br /> CONTACT 1 : Don 0. Culbertson / Chevron Pipe Line Co. (_Q) 842 - 6930 — (_) <br /> CONTACT 2 : Bob Butler / ( 1Q) 84.26()29 <_> <br /> DESIGImATED EMPLOYEE # 684 PROGRAM ELEMENT # 29.60 CURRENT STATUS <br /> Al OF UNITS EPA 10 #: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site sd/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party Identified as the <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all applicable A JOAOUIN C OMIT rddi/inane Codes�ard/cr Standards and State end/or Federal lame. <br /> APPLICANT'S SIGNATURE : '�i' � z-0 <br /> Title: Environmental Specialist Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of arry and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIViSION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> 234.00 234.00Z000)OOS05j <br /> lir <br /> RENS /� Sul _/_,J_ ACCT _J_J UNIT CLK ��f— <br />