SITE INFORMATION AND CORRESPONDENCE_FILE 1

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GENERAL PROGRAM FILE New _ Change Edit (PROG3) revised 8/26/93 FACILITY ID # FACILITY NAME P c3 �i�[tia>1/70se-,) RECORD ID # �� 3 PRIOR SWEEPS/CCMP * /Z� 7- DAIRY: Grade A Gr B Milk Dispenser Number of Containers in Multi-Head Unit FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant Seating Capacity Sq Ft Market w/Food Prep: Y / N Temoorary Food Facility Special Food Event Vending Machines Number of Vendine Unita Food Vehicle Make License # Registration # Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR HOUSING: Hotel/Motel No. of Units Jail/Exempt institution Housing Abatement Employee Housing No. of Employees Approx Dates of Occupancy —f / to LIOUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing Lg Generator Sia Generator Storage (2-10) _ Storage (11-50) _ Storage ( tso ) Transfer eta Ltd Hauler Vet Clinic RECREATIONAL HEALTH: Poo(/Spa Number of Pools Out of Service Pool Natural Bathing Place SITE MITIGATION: Environ Assess —)L UST/CAP Loc Haz Waste Haz Mat PPL C-1 Other Lead Agency Site Agency: RWOCB DTSC NPL Site RB/H20 0 Other SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fay Ag Waste/Exempt Site SW Vehicle No. Dumpster No. Stationary Compactor Site 2 D vECTOR CONTROL: Poultry Form Max Number of girds / /6 EM£PGENCY NOTIFICATION for this FACILITY and/or PROGRAM A N�, DAY /(a--7 7 30 0 0 NIGHT COHTACT 1 �/� ( y.� ; li��Y (�O ) / - 352Y ( ) CONTACT 2 4 ( ) - DESIGNATED EMPLOYEE # PROGRAM ELEMENT 0 2 j U CURRENT STATUS 0 OF UNITS EPA ID #: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of saw, acknowledge that all site and/or project specific PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that 1 have prepared this application end 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, when applicable, 1, the owner, operator or agent of same, of the proCerty located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envirorrnental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Fes! Amount Amount Paid Date of Payment Payment Type Receipt / Check 0 Recvd By /19� --e- REHS /�/` / �y / SUPV _/_� ACCT _J ! UNIT CLK _J_J