SITE INFORMATION AND CORRESPONDENCE

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GENERAL PROGRAM FiLE s New —$! Change Edit (PROG3) revised 5/21193 FACILITY ID ! FACILITY NAME 'ECORD ID ! PRIOR SWEEPS/COMP ! DAiRY: Grade A Grade B Milk Dispenser Number of Containers In Multf-Head Unit _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant Seating Capacity Sq Ft Market w/Food Prep: Y / N Temporary Food Facility Special Food Event Vending Machines Nuaber of Vending Units Food vehicle Make License 0 Registration ! Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE P8R _ HOUSING: Hotel/Motel No_ of Units Jail/Exempt institution Housing Abatement Employee Housing No. of Employees Approx Dates of Occupancy _! / to LiQUiD WASTE: PurTmr Vehicle Pum"r Yard Chemical Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled 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 X SiTE MITIGATION: Environ Assess UST/CAP _ Loc Haz Waste Haz Mat PPL Other Lead Agency Site Agency: RWOCB DiSC NPL Site R8/H20 0 Other _ SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fee Ag Waste/Exefrpt Site SW Vehicle No. Dump+ter No. Stationary Cor"etor Site VECTOR CONTROL: Poultry Form Max Number of Birds Kennet EMERGENCY NOTIFICATION for this JMR4M#qWqf PROGRAM ( soil borings ) DAY NIGHT CONTACT 1•t Janet Kappmever (Cyprpss ) (Ila&)Z.74 AZA �-�)7 —' Z5QF) — CONTACT 2 : Jim Kleinfelder (Spectrum) 12-Q.9—)465-8712 baa )C:-,21L-EQC)l DE§IGNATEO EMPLOYEE ! PROGRAM E[EMENT ! CURRENT STATUS ! OF UNITS : EPA 10 !: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that Ott site and/or project specific PHS/EHD hourly charges associated with this facility or activity wilt be bitted to the party identified as the BILLING PARTY on this fora. I also certify that t have prepared this application and that the work to be performed wilt be dory In accordance withapplics to SAN JOAOUIN TY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATU EE . reed - ex Evw;ro4" �qq� Title: - �I or Date- / AUTHORIZATt& TO RELEASE INFORMATION: in addition to the above, when applicabl , i, the owner, operator or agent of same, of the propertymlocated at the above aft* address hereby autherfze the release of any and all results, geotechnical data and/or envirormental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL WEALTH DIVISION as soon as .� it is evallable and at the same time it is provided to me or my representative. fee Amount Amount Paid Date of Payment Payment Type Receipt ! Check ! Reevd By . RENS _/�/ SUPV _/ / ACCT /_f UNIT CLK _/ /