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SAN JOAQUIN COUNTY Eh . RONMEINTAL FIEALTH DMS7 I <br /> 14IAST'ERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑Ncw EM PTERM at Existing Facility ❑New Eli PrOgam and New Facl11 <br /> ?F&cili ID ... .: Pr' Alii Record ID <br /> ,Facility Address 37 west Sonora Street <br /> (Please Check the appropriate description and specify Am number of ur)its and pertip nt inform flan.} <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage )good Handlers Course EMBired- YES❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ClVen01119 Mac111M—Number of Units_ <br /> ❑ Retail Market----Square footage ❑ with Meat Marktt only ❑ Multiple De"rtmentc ❑ Prepackaged Goods Only <br /> ❑ Mobile Food'Vehicle---Make Vebirlegype Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Uait--Make _ Vehicic Type Color <br /> Registration# License f► Sticker# <br /> ❑ Ternpgrarr Food F•acitity----Dates of operation from t4 ❑ Ice Plant <br /> Special Event - Dates of operation from 10 ❑ 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 5urchar.t(2399) <br /> HAZARDOUS WASTE PROGRAM(2204) <br /> ❑ Hazardous Waste GeneratorGenerated Per Year <br /> Ticred Permitting Facility ❑ Conditionally Authori2ed(CA) ❑ Conditionally.Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household hazardous Waste <br /> ❑ AROVEGROUND STORAGE TANK 1±ACILITY(AST)(2390)----Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use[ZETA and B roans <br /> HORSING PROGRAM(2400) <br /> ❑ NotellMotel------Number of Units d .Sall or Exempt institution--Number of Unite _ <br /> Employee}Cousin=(2700)Use EM210290 R0 /Labor Camiz A ppumduff Form <br /> 31TE MITIGATIQN(2900) U DERGROUN"NJ-9"1QN CDNTRQL(3000) <br /> R.Aronmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECeREATIONAL HEAL" PROGRAM(3600) <br /> Number ofPools/Spas at Facility ❑ Pool Cl Spa ❑Out of Service Pool/Spx ❑ Natural Dathing Area <br /> VECTOR CONYROL PRO4RANI(4004) <br /> ❑ Poultry Farm Maximum numt�er of birds ❑ Kennel <br /> 1&T—mo 111 00_y PIERCING PERNIAHRNIT CO3 ETIC PRO*RAM(4 100) <br /> ❑Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> 1 UID TR PRO RAM(4200) <br /> ❑ Pamptr Vehicle—Registration# Lieense# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemlcal Toilets-----Number of Units <br /> ' SOLID MYASTE PR (4400) <br /> ❑ Landfill 0 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Ficwty i3 Compost Facility ❑ Process/Reeyele Facility ❑ CIA Landfill Site <br /> I ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MPRICALWASIEPROGRA (4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing 0 Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic Cl Common Storage Facility---❑ 2- 10---- ❑ [1 -60---❑ >60 generators <br /> PUBLIC WATER SY$TEM PROGRAM(4600) Use PWS ER0069 Bltre Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANWOR PROGRAM <br /> 'PONT CT PERSON Day Ph Night Ph <br /> PROGRAM EL9 HENT FEE ❑ Surcharge F€E ❑ Other nE _ <br /> INSPEC•rok# PEIZMCf VALID to ❑ Food Handler <br /> ❑ Cbeok# _ AMouNT PAID Date INVOICE# <br /> ❑ Cosh i t Ewt"o K3Y ACCOUN rrNG OFncs Date <br /> EH 000 PTNKC 1--ORM.dnc <br />