SITE INFORMATION AND CORRESPONDENCE

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For APA 19 GENERAL PROGRAM FILE : New Change Edit (PROG3) revised 5/21/93 FACILITY ID # FACILITY NAME RECORD ID 9 PRIOR SWEEPS/COMP # DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant Seating Capacity Sq Ft Mar et w/Food Prep: Y / N Temporary Food Facility Special Food Event Nending Machines Number of Vending Units Food Vehicle Make License # Registration # rotor HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR HOUSING: Hotel/Mote! No. of Units Jail/Exempt Institution Housing Abatement Employee Housing No. of Employees Approx Dates of Occupancy _J / to LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant MEDICAL WASTE: Primary Care Acute Care Skill, Nursing Lg Generator Sm Generator Storage (2-10) _ Storage (11-50) _ Storage ( >50 ) Transfer Ste Ltd Hauler Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place V/SITE MITIGATION: Environ Assess UST/CAP t,"� Loc Ham Waste Naz Mat PPL Other Lead Agency Site Agency: RWGCB DTSC I NPL Site RB/H20 0 Other SOLID WASTE: Landfill _ Transfer Sta Recyciing Fac L Waste Storage Fac Ag Waste/Exempt Site SW Vehicle _ No. Dempster No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 : CONTACT 2 DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS N OF UNITS _ EPA ID #: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that ail site and/or project specific PHS/EHD hourly charges associated with this facilitf or activity will be billed to the parry 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. APPLICANT'S SIGNATURE Title- Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, whe applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the IIelease of any and all results, geotechnical data and/or envirormental/site assessment information to SAN JOAQUIN COUNTY PU8LIC 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 Payment Payment Type Receipt # Check it Recvd By a RENS ____/ / 5U 7 �/� ACCT �/ UNIT CLK _� J