SITE INFORMATION AND CORRESPONDENCE

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'GENERAL.PROGRAM FILE New Change Edi[ (PROC3) revised 8/26/97 FACILITY 10 I FACILITY NAME Alden Park/City of Tracy/Various Residents RECORD 10 M PRIOR SWEEPS/COMP I DAIRY: Greek A Grade B Milk Dispenser Number of Contsiners in MuLtl-HeaA Unit FOOD: Restaurant Market Commissary Mobile Food Produce S dant Seating Capacity Sci Ft Market w/Food Prep- T / Temporary Food Facility _ Special Food Event _ Vending Machines _, Muaber tiding [mita Food Vehicle _ Make License I Registration I Color , HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Fac 1l)ty : CA _ CE _ FOR _ HOUSING: Hotet/Hotel No. of Units Jsll/Except institution Housing Abatement Employee Housing No. of Employees Approx Bet" of Occupancy _/_/_ to _ LIOUIO WASTE: Pumper Vehicle i Purper Yard Chemical Toilets No. Package Tx Plant MEDICAL WASTE: Primary Care Acute Care Skilled Nuroing Lg Generator _ Sm Generator Storage (2-10) _ Storage (11-80) _ Storage t +90 ) Trus for Its _ Ltd Hauler _ Vet Clfnic _ _ RECREATIONAL HEALTH: Pool/Spa _ Number of Pools Out of Service Pool _ Natural Bathing Place X SITE MITIGATION: Environ Assess UST/CAP _ Loc Hat West* _ Hai Met PPL Other Lead Agency Site _ Agency: RWOCS x OTSC NPL Site _ RB/H2O 0 _ Other _ SOLID WASTE: Landfill "Transfer Ste _ Recycling Fac Vesta Storage FeeIA-e�VNg--tFj1E SW Vehicle Vehicle _ No. Du,npster _ No, Stat1 F9.CdYIlilt VECTOR CONTROLe Poultry Form _ Max Number of Birds Kemal H IN d�1QC ••� umm EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT ENVIRONMENTAL HEALTH CONTACT 1 Don 0. Culbertson/Chevron Pipe Line Co- (_UL) 842 6930 PERkAELS5RVICE�, CONTACT 2 : Bob Butler / N11 ( w) R42_ lig2g (_) DESIGNATED EMPLOYEE I 684 PROGRAM ELEMENT I P9.60 CURRENT STATUS I OF UNITS - EPA ID I: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sow, acknowledge that all sit• and/or project specific PHS/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 a ti}y that I have prepared this application and that the work to be performed will be done to accordance with all applicable SA OIlOUIN C Y 0nce codes and/or Standards and State and/or Federal laws D APPLICANT'S SIGNATURE Title: Environmental Specialist Date. GA(o91 AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicab�he over, operator or agent of sae*, of the prwerty located at the above site address hereby authorfte the release of arty and dl results, geotedmical date antVor envirormental/site assessment information to SAM JOA0UIM COINTT 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 Onto of Payment Payment Type Receipt I Check I Recvd By 234.00 234.00 RENS _/_J_ SUPv _/_/_ ACCT UN CLK �__J—