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N <br /> SAN JOAQUIN COUNTY DINIVIRONIMEN`I'AL IILALTII DEI'AR`I MEN`I' <br /> Mil STERFILE RE,CORD INFOPMATION FORM _ <br /> �194Jew EI1 Program at Existiag-Facility _A _ ❑Ncv.,Ell Program and New Facility_ <br /> �acilit} ID �" j��_ -- Pro�rant IZccord ID <br /> P� S3 � <br /> Facility Address rD:�50 LjV7ne_ <br /> (Please Check the appropriate description and specify sue,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage food Handlers Course required: YES El NO El <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail lliarket—Square footage ❑with Meat lltarkel only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehic(c---Make Vchicle 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-head Unit <br /> COPA ❑ Slate Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle(Exenipl System(2299) <br /> ❑ CRT Offsite Handlers (2218) El Silver Only(2222) _ El Appliance Rccyclers(2217) <br /> Tiered Pern;Iitting Facilify ❑ Coaditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Perriut-By-Rule household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and F rarrus <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> ]Employee I[ousing(2700) Use Fnrpropee IfousinKabor Camp APplicafiort FOrn <br /> SITE MITIGATI014(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Enlironmeatal Assessment ❑ UST-CAI'Site ❑ Local 11"'Cleanup Site ❑ NPLdSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIIN'Site ❑ non-NPUSEP 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 serriee Pool/Spa ❑ Natural Bathing Area <br /> VECTOR COIITROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERGRIG PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Pard ❑Package Treatment I'lant" ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Studge/Ash Site <br /> M45'aste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA.Landfill Site <br /> ❑ Refuse Vehicles—Numbcr of Units ❑ Dump_ters>20 cu yd —Number of Units ❑ I:arm/Isnch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ barge Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Vcteriunry Clinic ❑ Common Storage Facility—El 2- 10---❑ 11 -6o---- ❑ 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) (Ise PHI';' F111) (6-01-003 iifarjoplica6all For rtr <br /> EPrIERGEHCY HOTIRCATIOH FOR Tiffs FACILITY ANDIOR PROGRAM <br /> CONTACTPERSON[ Day Ph —Nit,lit Pli <br /> 1't?0GR:?N11",LYNtt=t,:T Surcharge FEF ❑ tither f' E <br /> IN5PECTOV,4 a6ao PEN2.111VALID t,o f=i Food handler <br /> Cl 11�ccI,tr_ ��1`It�l Ii•li'I'•i IU _ __ 1)�(r li Nt�l�"I?11 T__ <br /> ❑ Ca,h I �'.'tE1,lLpttT Arri t_rl4rit: ;i_Irrl,_F---- l�ai_ l9 �� ({ v — — <br />