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SAN JOAQUIN COUNTY ENVIRONMENTAL H=PARTMENT <br /> MASTERFILE RECORD INFORMATIO <br /> ❑New EH Program at Exiistin Facility []New EH Proe=and New Facility <br /> — <br /> Facility ID J 17 U' p S7 Program Record ID <br /> Facility Address 10 r/ f✓ ° CY�t a <br /> (Please(Neck the appropriate description and specify gm number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# ' <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility---Data of operation from - to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) - - <br /> ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200)- t <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑P By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST —I - - <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use US7'A and B orm <br /> HOUSI G PROGRAM(2400) <br /> ❑HoteVMotel Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employ"Housing(2700)Use Employee 71ousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑ nou-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Qaality Remediation Site <br /> RECRFA'110NAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm—Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> LI Tattooing(412 1) 11 Body Piercing(4120) [3 Permanent Cosmetic(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration If License# Capacity Vehicle <br /> ❑ Pumper Yard . ❑Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 eu yd Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4$00) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--❑ 2-10—❑ 11-60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EUD 66-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON O r1, Day Ph Night Ph <br /> PROGRAM ELEAIENT ? 87D FEE ❑ Surcharge FEE- [I Other FEE <br /> INSPECTOR# , $ PERMrTVALID to <br /> 11 Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# I <br /> 0Cash REVIEWED BY ACCOUNTING OFFICE Date <br />