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Sit N JOAQIIIN COUNTY IJN�r'IRONMENTAL IIL ALTA 1111I' IZT11tI NT <br /> t NIASTERFILE ILECORD INFORMATION FORM — <br /> N New EH I'rograrrnt at Exists Facility ❑Neyr EH Program and New Faacility— <br /> Facility ID r 5'79 grata Record ID P fw 5"3ri g3 _ <br /> Facility Address 1��1 �1 �cO�t�wuy� AV� - S�oc�2�Dr� <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> F=OOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: l'ES ❑ NO ❑ <br /> ❑fending Machines—Number of Units <br /> ElCommissary ElDry storage only [Iwitli Food Preparation <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 tt <br /> ❑ ]Mobile Food Prep Unit—Mahe Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000 <br /> ❑ ® )wiilkDispenser--Number of Containers in h{ulta head Unit <br /> Grade A Dairy El Grade B Dairy <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑hazardous Waste(Bcnerator-- Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2216) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility - ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-lay-Rule Fixed Unit ❑Pernut-By-Rule household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANI{FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and ft Lormes <br /> FIOl1SING PROGRAM(2400) <br /> ® <br /> El hoteni lotel Number of Units Jail or Exempt Institution--Number of Units <br /> )Employee housing(2700) Use l mp[opee jfocrsiric/ bor Carrrlr ApE[icaliorc Fomi <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION COHTROL(3000) <br /> ❑ EnAro n mental Assessment ❑UST-CAP Site ❑Local HSV Cleanup Site, ❑ NPLfSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIIV Site ❑ non-NPL(SEP Cleanup Site ❑RWQC13 Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL FIEALTH PROGRAM(3600) <br /> Number of PcolslSpas at Facility []Pool ElSpa E]out of Scrti2ce Pool/Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> El Tattooing(4121) ❑ Body Piercing(4120) El Permanent Cosmetic(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 IJ Transfer Station El Ag I CanneryWaste Site ❑ Sludge/Asir Site <br /> CR Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ P,,efnse N'elLicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ Farm/ILnch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care F71 Acute Care El Skilled Nursing El Large Generator E] Small Gcacrator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2- I O ❑ 11-6o---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use 1'If'SFT[D dE-02-003 Rlrrc AnPlicaliorr,form <br /> IEMERGEPiCY NOTIFICATION FOR wis FACILITY AND[OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph - --- <br /> PROGiLAmFLENIENT— flL(0 I"EE T ❑ Surcharge FEE ❑ Other FEF <br /> INSPECTOR'# I'f�1,1111- rALTD to ❑ Food handler _ <br /> ❑ check K AmOUNT PAID _ _ Dale ]NvolcF It — <br /> ❑ Cash REVIc�rr_r�t+Y tit Lv ACCOUNTING OFFICE -- ---- Date _--- <br />