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SAN, JOAQUIN COUNTY ET ` RONMENTAL HEALTH DEPAR. SENT INFORMATION FORM EH Proerzm at Facility Address (2S S N t) f D FI -N bi-. (Please Check the appropriate description and specify sizenumber of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units ❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only _ ❑ Mobile Food Vehicle ----Make Registration # Mobile Food Prep Unit --Make Registration # ❑ Temporary Food Facility -----Dates of operation ❑ Special Event --Dates of operation from_ DAIRY PROGRAM (2000) from Vehicle Type License # _ Color Sticker # Vehicle Type Color License # _ Sticker # to ❑ Ice Plant ❑ Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser --Number of Containers in Multi -Head Unit COPA ❑ State Facility Surcharge (2399) / HAZARDOUS WASTE PROGRAM (2200) 19(Jiazardous Waste Generator ---------Tons Generated Per Year 1L1 ❑ Recycle / Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑.Permit -By -Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing (2700) Use Employee Housinr/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL 3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm ---Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑Pumper Vehicle --Registration#. License # Capacity Vehicle# ❑ Pumper Yard 6 ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 to yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- 02-10 ------- 011-60 ------❑ > 60 generators 4M2-034 10/6/2003