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SAN IOAQUIN COUNTY 1;NVIRONAIENTAL IIIJALTI1 DEPARTMENT <br /> 11IASTERFILE RECORD INFOfOIATION FORIA <br /> ❑New EH Program at EXistln Facility fi #ew EH Program and New Facility <br /> Facility fl) r_010 D \3 Pro ram Record ID <br /> Facility Address <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: Yss❑ No ❑ <br /> ❑ CommissaryElDry storage only Elwith Food Preparation El Vending Machines—Number of Units <br /> ElRetail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vchicle--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 El Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Mufti-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS`VASTE PROGRAM(2200)' a <br /> ❑hazardous Waste Generator----Tons Generated Per Year ❑ Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pem it-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 roans <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/I11otel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee I{ousing(2700)Use Etnployee Ifousin&Labor Camp Applica6arr Form <br /> SITE MITIGATION(2900) UNDERGROUND INJEGTION CONTROL(3000) <br /> ElEnAronmeatal Assessment ❑ UST-CAP Site 11 Local IBV Cleanup Site, ElNPUSEP Cleanup Site ❑UTC Site <br /> ❑ Abandoned IINV Site Elnon-NPI.lSEP Cleanup Site ElR�VQCB Cleanup Site ❑NVater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service PoolfSpa ❑Natural Bathing-Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11Poultry Farm Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration tt License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant. ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> 03Vaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 11 CIA,Landfill Site <br /> El Refuse Vehicles—Number of Units 11Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2- 10 ❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) UsePff'SIffD46-02-003 BlucApplicationForst <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PR0GR4NtELEl11Er,T_Z/7-YO ` FEE El SurchargeFEE ElOther FEE <br /> INSPECTOi# v26.jc? PERhfITVALID —_— to ❑ Food handler__ <br /> ❑ C.h«x V AmouN-r P Axo Date I11VOICE 1# _-- --- <br /> ❑ Cash IC1iViFVIED BY AccouttTiid l OFFICE _ �y�-_Date __— <br />