SITE INFORMATION AND CORRESPONDENCE_CASE 1

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GENERAL PROGRAM FiLE : New Change Edit (PROG3) revised 5/21/93 FACILITY ID 0 FACILITY NAME X),6_ �U RECORD ID 0 PRIOR SWEEPS/COMP A DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Need 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 Llcense N Registration N Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility CA CE PON _ HOUSINGs Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement Employee Housing No, of Employees Approx Oates of Occupancy _J_1_ to __f___/ _ LIQUID WASTES 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 ( >SO ) Transfer Sto Ltd Hauler Vet Clinic _ RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool Natural Bathing Place SiTE MITIGATION: Environ Assess UST/CAP Loc Hez Waste Haz Met PPL Other Lead Agency Site Agency: RWOCB OTSC NPL Site 118/1120 0 Other _ SOLID WASTE: Landfill Transfer Ste Recycling Fsc Waste Storage foe Ag Waste/Exempt Site SW Vehicle No. Oumpater No. Stationary Compactor Site VECTOR CONTROL: Poultry Farms Max Nuntr_r of Birds Kennel EMERGENCY NOTIFICATION for this FACILITY end/or PROGRAM DAY NIGHT CONTACT 1': ( ) ( ) CONTACT 2 ( ( ) OE§IGNATEO EMPLOYEE 11 T PROGRAM ELEMENT mf T_ CURRENT STATUS 0 OF UNITS EPA ID S: INSPECTION CODE BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific PNS/EHD 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 i have prepared this application and that the work to be performed will be done In accordance with sit applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal taws. / APPLICANT'S SIGNATURE Page 1011 Title• Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/sits 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. Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check 0 Recvd By 77l D Aov 70,26.,DU _4e_� SUPV _/ / ( ACCT ��/ I D / UNIT CLK _/ /