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SAN JOAQUIN COUNTY ENVIRONMENTAL I1EA1_TI1 DEPARTMENT <br /> h1ASTER.FILE RECORD <br /> INFORMATION FOR111 <br /> :1 New EH Program at Existing Facility KNew EH Program and New Facility <br /> Facility ID A- 00/q�2c _., Pro ram Record ID 1p_1. �r�� <br /> Facility Address —`�G��ll ���os1 Sk- ��n��'L}nA,(A 95���0 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No 11 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑\'ending 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—Dates of operation from to [I ice Plant <br /> ❑ Special Event —Dates of operation from to 11 Produce Stand <br /> DAIRY PROGRAM(20W) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Numbcr of Containers in Mufti-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) d <br /> ❑ hazardous Waste GeneralIor--- Tons Generated Per Year ❑ Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ notel/1\Iotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Fmployee Housin,/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑ Local MV Cleanup Site. 11NP11SEP Cleanup Site ElUIC Site <br /> ❑ Abandoned IIW Site 11non-NPLISEP Cleanup Site 11anup <br /> RWQCB Cleanup Site ❑ Nater Quality Remediation Site <br /> RECREATIONAL 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 /> [IPoultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# 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 /> M Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care ❑ Acute Care El Skilled Nursing 1:1 Large Generator ❑ Small Generator ❑ Limited Hauler <br /> lTransfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---112- 10 ❑ 11 -6o--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PII'SFHD 46-02-003 BlucApplica[ion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> i <br /> PROGRANt ELEMENT Lk-1 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# a�D�-� PEFM]TVALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> V9=15 <br /> ❑ Cash REVIEWED BY 'J� �1 q 1D ACCOUNTING OFFICE Date <br />