SITE INFORMATION AND CORRESPONDENCE

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CNERAL PROGRAM FILE New Chnnge Edit (PROG3) revised 5/21/93 FACILITY 10 R D ---- FACILITY NAME —__—� ---- - --_- --- RECORD ID R ■ 11/1 PRIOR SWEEPS/COMP e — DAIRY: Grade A Grade R Milk Dispenser Nuarbe.r of Containers In Multi-Head Unit FOOD: Restaurant Markt Ctxrmissany Mobile rood Procluce Stand Ice Plant _ i — Seating Capacity Scl Ft Mnrket w/rood Prep: Y / N Temporary Food Facility _ Special Food Event ___ Verdlny Mnchines _ Ntxrber of Vending Unite Food Vehicle Make License R Registratim R Color HAZARDOUS WASTE: Tons Generated/Yr _ TIERED PERMIT Facllity : CA _ CE _ FOR HOUSING: Hotel/Motel No. of (Ants Jnil/Exempt Institution Housing Abatement Eaployee Housing _ No. of Employees Approx Dates of Occupancy _/`/_ to _ LIQUID WASTE: Pumper Vehicle Ptxrper Yard _ _ Chemical Toilets _ No. Package Tx Plant — MEDICAL WASTE: Primery Care Acute Cnre Skilled Nursing _ Lg Generator _ Sm Generator _ Storage (2-10) _ Storage (11-50) _ Storage ( 150 ) Trmisfer Ste — Ltd Hauler _ Vet Clinic RECREATIONAL HEALTH: Pool/Spa _ Number of Poole __ Out of Service Pool _ Natural Bathing Piece _ SITE MITIGATION- Environ Assess X UST/CAP Loc Noz Wnste _ Hat Hat PPL Other Lead Agency Site _ Agency: RWOCR DISC _ HPL Site _ R8/1120 0 _ Other — SOLID WASTE: Landfill Transfer Ste RecycUng Fnc _ Waste Storage Fac _ Ag Waste/Exempt Site SW Vehicle No. DiAMAter _ No. Stetlonary Compactor Site _ VECTOR CONTROL: Poultry Form _ Max Nuder of Birds Kernel _ EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 1 Nancy Bond ( SECOR ) (415 ) 882 . 1548 (41 5) 731- 7759 CONTACT 2 : JolynnHH- aanrdiman SECOR (415 ) 882 - 1548 (415) 389 69. 52 DESIGNATED EMPLOYEE R PROGRAM ELEMENT r CURRENT STATUS R OF UNITS : / EPA ID R: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: It the undersigned owner, operator or agent of same, acknowledge thet sit site and/or project specific PNS/EHO hourly charges associated with this facility or activity will be billed ttothdl�iahk� Identified as the BILLING PARTY on this form. i also certify that I have prepared this application and that the vofko'bepakloomed will be done In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal ,laws. NIM — APPLICANT'S SIGNATURE Project Manager Date: b �gnivioU BLIO HEALTH SEN VIC E, 1z(fkf' 1011Title: -".LTH AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of-same, of the property-toasted at the abavz site address hereby authorize the release of any and all results, geotechnical data and/or env(romental/sits assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same tine It is provided to me or my representative. Fee Amount Amort Paid Date of Payment Payment Type Receipt R Check R Recvd By SUN / __/_ ACCT / —%/—qUNIT CLK _/ /_