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06/04/99
<br /> FRI 5:55 FAX
<br /> 209 948 0621 KLEINFELDER INC U004f.ilY 'li'/t1t iL•r �'1 ,I' r� e 4T >r f� �I n�IT �` �� P rel✓ 0.
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<br /> EYployee Nan ing `"Ii°%No of'E L Tees r' ti�— `,NaunlNiq AbetP .y -, .
<br /> ,* aP,W _ AT.prox Oates of Uceupency
<br /> LI WIDWASTEs PNmar Vehicle +' pItiY, alrg '�i l
<br /> Asrper Yard i. Chemical Tollaa No t P�ekj
<br /> _ MEDICAL WASTE: `PrfNre Carat ' `
<br /> fY' Acute Care Skilled Rural 4 3��
<br /> storage 2•,10) .' ' `"� no _ LO Generator 5Ya O nera�ar
<br /> W < Storage (Tf-50) IT Stafapa'(.>50 ) Transfer 9teA1-std Nwldrr ' e t Vinic .
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<br /> RECREATIONAL NEALTNt ,Pool/Spa _ Nurbe'r of pools Out of service Pool Net(irel Seth SSL
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<br /> _ SITE MITIRATIONs Environ Assess USOCAP % Lac Ilaz Waste Nez Mat'PPL `
<br /> Other lead Agency Site 'Agency: RLACB,_ DISC — NPL Site RB/H2O 0 _„Other. .
<br /> SOL 10 WASTES Landfill - "transfer Ste -B Recycling Fnc — Naete storage Fee AR Neste/Exectit Site _
<br /> SW Vehicle No. Oumcter No.
<br /> Stationary ry C ompactor Site
<br /> _, VECTOR CONTROL: Poultry Fars — Max Nuiber of Birds Kernel
<br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAT
<br /> .�7 MIGHT
<br /> CONTACT 1"1
<br /> CONTACT 2
<br /> MIGRATED EINLOTEE / , PROGRAM ELEMENT B CURRENT STATUS
<br /> g OF UNITS I _, EPA ID S:
<br /> INSPECTION CODE
<br /> SILLING and COMPLIANCE ACIMAEDGEMENT: 1, the undersigned owner, operator or agent of same, sclumw(edge
<br /> that
<br /> project Specific PMS/END hasty Charges associated with this facility or activity Witt be blued to the partyIdentified ski/or the
<br /> BILLING PARTY on this form. 1 also certify that I have prepared this application and that the work to be performed will be done
<br /> In accordance with all applicable SAN JOAOUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal laws.
<br /> APPLICANT'S f)GNATURE i
<br /> ritIt:� -n_ t
<br /> opip,,,�,Te: fake 1011
<br /> AUtHOR I2ATlON TWRELEASE INFORMATION: In addition to the aboveappt leeb , 1, t s oNnar, "rotor or event of same, of
<br /> the property'(oertad ■t the Above site address hereby authorize the release of any and all results
<br /> geotechnfcal
<br /> mvirormentat/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIONsass000n as
<br /> It is evalloble and at the same time It is provided to Re or my representative.
<br /> Fee Amount Amount Paid
<br /> Date of Payment Payment Type Re<elpt N Cheek s Recvd By
<br /> RENS / n SUPV
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