Laserfiche WebLink
GENERAL PROGRAM FILE New �_ Change X Edit (PROG3) revised 8/26193 <br /> FACILITY ID A FACILITY NAME Alden Park / City of Tracy <br /> [:RECORD 10 N PRIOR SWEEPS/COMP f 9067 <br /> DAIRY: Grade A Grade B _ Milk Dispenser Nurber of Containers in Multi-Head Unit <br /> FOOD: Restaurant _ Market _ Commissary _ Mobil• Food — Produce Stand _ Ice Plant _ <br /> Seating Capacity Sq Ft Market w/Food Prep: T / N <br /> Tenoor Rry Food Facility _ Special Food Event _ Vending Machines _ 14mbor of Vedins units <br /> Food Vehicle Make License N Reglatratl on N Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _ POR <br /> HOUSING: Hotel/Motel No, of Units Jall/Exmpt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy _/_J_ to <br /> LIQUID WASTE: Purper Vehicle Purper Yard Chemical Tollets No. Package Tx Plant _ <br /> _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing _ Lg Generator _ Aa Generator <br /> Storage (2-10) _ Storage (11-50) _ Storage ( +SO ) Transfer at• _ Ltd Hauler _ Vet Clinic _ <br /> _ RECREATIONAL HEALTH: Pool/Spa Nurber of Pocls Out of Service Pool _ Natural Bathing Place <br /> X SITE MITIGATION: Environ Assess UST/CAP Loc Hat Waste _ Hat Mat PPL _ <br /> Other Lead Agency Site X Agency: RWDCB X DISC MPL Site _ RS/1120 0 _ Other <br /> _ SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac _ Ag W �� <br /> SW Vehicle _ No. Duipster No. Stationae ry C 1j <br /> VECTOR CONTROLi Poultry Ferro _ Max Number of girds Kernel _ JUN 8 199.5 <br /> EMF.RGEHr,Y NOTIFICATION for this FACILITY end/or PROGRAM DAT NIGHT <br /> ENVIRONMENTAL HEALTH <br /> CONTACT I : Don 0. Culbertson / Chevron Pipe Line Co. (.M) 842 - <br /> 6930 1 PlRMIT/S1,RVICES <br /> CONTACT 2 - Bob Butler / 11 'I (_M)_$42 6� (—) <br /> DESIGNATED EMPLOYEE d 684 PROGRAM ELEMENT s 29.60 CURRENT STATUS <br /> s OF UNITS - EPA 10 a: INSPECTION CODE <br /> BILLING and COMPLIANCE ACKNCWLEDGEMENT: 1, the undersigned owner, operator or agent of seas, acknowledge that all site and/or <br /> project epeciflc PHS/EHO 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 perforied will be done <br /> In accordance with sit applicable A JOAOUI C T rdl note Codes ad/or Standards std State and/or Pedant laws. <br /> APPLICANT'S SIGNATURE �� <br /> Title: Environmental Specialist Dau: (0j2 4�`!S^ IN, : <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of seise, of <br /> the property located at the above site address hereby authorize the release of wrf and all results, geotadtnical data and/or <br /> environmental/site assessment inforartlon to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the same tins it is provided to ma or nay representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt Al Check 0 Ilecvd By <br /> 234.00 234.00 <br /> REMS / SUPV ACCT UNIT CLK _J_�— <br />