SITE INFORMATION AND CORRESPONDENCE

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GENE?AL PROGRAM FILE New Change edit (PROG3) revised E/26/93 } FACILITY 10 ! / 7G Q FACILITY NAME RECCRO IO ! �Cc7 �� PRIOR SWEEPS/CCKP ! DAIRY: Grade A Grade 3 Milk Dispenser Nurber of Containers in Multi-Head Unit _ FOOD: Restaurant Market Commissary Mobite Food Produce Stand Ice Plant Seating Capacity So Ft Market w/food Prep: T / N Twncoorary Food Facility Special Food Event Vending Machines Ntaber of Vardine Unita Food Vehicle Make License ! Registration it Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PSR _ HCUSiNG: Hotel/Motet Na. of Units Jait/Exeept Institution Housing Abet Emaloyee Housing No. of Employees Approx Dates of Occupancy _f_� to LIQUID 'TASTE: Pumper Vehicle Pumper Tard Chemical Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing La G~stor 9e Generator Storage (2-10) _ Storage (11-90) _ Storage ( 3,10 ) Transfer Sts Ltd Hauler _ Vet Clinic .qECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural 3athing Place y SITE MITIGATION: Environ Assess UST/CAP Loc Hat Waste -Y— Naz Mat PPL Other Lead Agency Site Agency: RSAC3 DISC NPL Site RS/H20 g Other _ SOLID 'TASTE: Landfill Transfer Sta Recycling Fse Waste Storage Fac Ag Vaste/Exespt Site SW Vehicle No. Dumpster No. Stationary Coapeetor Site VE_TOR COMTRCL: Poultry Farm Max Number of Sirds 1Cervxl ^MERGENCT 4OTIFICATION for this FACILITT and/or PROGRAM DAY MIGHT C1,+1TAC7 1 ( ) ( ) CCNTACT 2 DESIGNATED EMPLOYEE ! o6gC>< PROGRAM ELmma ! Z9 53 CLMYJDfT STATUS I ! OF UNITS EPA ID it: INSPECTION 1CCDE I 3ILLING and CCMPLIANCE ACXNCWLEDGZ4W: I, the undersigned owner, operator or agent of sag, ackr4aAadoe that sit site and/or prof specific PHS/EHD hourly charges assoeisted with this facility or activity Witt be bitted to the party identified as the -'r 3ILLING PARTT on this fora. I also certify that I ljdve prepared this application and that the Work to be performed will be done in accordance with alt applicable I Ordinenca Caries and/or Standards and State and/or Federal Leta- APPLICANT'S SIGNATURE f Title: f+.�rdT i`o l lU,aep1 ,a '0150e/TI'- 4 Data: /I/i l 4' AUTHCRIZATICN TO 2E7-EASE INFORMATION: In sddition to the above, when applicable, I, the otsner, operator agent of sauna, of the property Located at the above site address hereby authorize the release of any and all results, geotechnicst data srxi/or envirorn+encat/site assessment information to SAN JOAGIIIN COJNTT PV8LIC HEALTH 93YIMS 9 IRONMENTAL HEALTH DIVISICN as soon As it is available and at the same time it is provided to ore or ally representative. Fee amount Amount Paid I Date of Payment (Payment Type I Receipt ! check ! Recyd 3Y moo:- I 1111 IIIIA I I ACC UNIT CU ��J