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JOAQUIN COUNTY ENVIRONi1]ENTAL HEAL"1'11 DIVISION <br /> NIASTE'RFILE RF 21) INFORMATION FORM (F.II 00 69) <br /> ew EI I Program at Existing Facility ❑New El I Pro gram and New Facility <br /> Lacility ID Program Record ll) _51,5,3e� Rts /f- <br /> ,Facility Address <br /> Please Check the appropriate descri ption and specify size number of units and pertinent information.) JUL 2 8,�`""" <br /> ( 1 P Y � , <br /> FOOD PROGRAM(1600) SAhd.1UAUUIN Ci:;+,�l7y <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Coutes Q..H�C V c PiVO ❑ <br /> Illiz;, <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-----Dates 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-}lead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ hazardous Waste Generator-----------------------Tons Generated Per Year <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(US"r) PROGRAM(2300)Use U.STA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ llotel/Motel-------Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee(lousing(2700) Use Errrliloree llou.cine/l.abor Camly Applica{ion Form <br /> S�TIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Lnvironmental Assessment ❑ UST-CAP Site ❑ Local (INV Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IINV Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water 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 /> ❑ Poultry Farm-----Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> 1113'UID 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 NVaste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd ----Number of Units ❑ Farm/Manch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ limited Ilauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----13 2- 10-------❑ 1 1 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use Pli S E110069 Blue Application Foran <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph _ Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> Check# ��� ANIOUNT PAID Date 4 INVOICES#1 <br /> Cash REvirWED BY ACCOUNTING OFFICE Date <br /> Eli 0061}PINK FORNI.doc Rw.07/07/99 <br />