SITE INFORMATION AND CORRESPONDENCE

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S P GENERAL PROGRAM FiLE : New Change Edit (PROG3) revised 5/21/93 FACILITY 10 # ol 0 71_8 FACILITY NAME RECORD 10 # � 7 7 PRIOR SWEEPS/COMP N DAIRY: Grade A Grade 8 Milk Dfspenser Number of Containers in Multi-Heed 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 Number of Vending Units Food Vehicle Make Licence N Registratiori N 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 _/ / to LIOU1D WASTE: Pumper Vehicle Pumper 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 ) Tronsfer Ste Ltd Hauler Vet Clinic RECREATIONAL HEALTH: Poot/Spa Ntnmber of Pools Out of Service Pool Natural Bathing Place v/SiTE MITIGATION: Environ Assess V---'UST/CAP /UST/CAP Loc 11az Waste Haz Hat PPL Other Lead Agency Site Agency: RWOCB DiSC NPL Site RB/H20 D Other _ SOLID WASTE: Landfill Transfer Ste Recycling Fac Waste Storage Fee Ag Waste/Exempt Site SW Vehicle No. Ounpater No. Stationary Compactor Site VECTOR CONTROL: Poultry Farm Max Number of Bfrds Kernel EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1't CONTACT 2 DEtIGHATEO EMPLOYEE 0 �-- PROGRAM ELEMENT # �<� CURRENT STATUS ? # OF UNITS EPA i0 N: INSPECTION CODE 3O BILLING and COMPLIANCE ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific PHS/EHD hourly charges associated with this facility or activity wilt be billed to the party Identified as the BILLING PARTY on this form. t also certify that i have prepared this application and that the work to be performed wilt ie done In accordance with alt applicable SAN JOAQUiN/COUNTY Ordinance Codes and/or Standards and State and/or Federal laws. APPLICANT'S SIGNATURE C / mac• Title• ✓1rp►.�w.eyn �� Pe61 eC('-'S e— Date: !��9� Page IOII AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of the property'tocated at the above site address hereby authorize the release of any and all results, geotechnical data end/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENViROiMENTAL HEALTH DIVISION as soon as It is available and at the same time it is provided to me or my representative. Fee Amount Amount Paid Date of Payment Payment Type Receipt M Check R Recvd By �3 e� ��3�^ �3 33 SUPV `�! / ACCT �/ �� / UNiT CLK _/ /