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SAN JOAQQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> NIASTERFILE RECORD INFORMATION FORM. <br /> (_New Eli Program at Existing Facility ❑New Eli Program and Ness l,'acility <br /> Facilit ID Proram Record ID 53 S <br /> Facility Address SG ✓r'1 <br /> (Please Check the appropriate description and specify size,number of units and Pertinent information) <br /> l=00D PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes El No 11 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vendia-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 /> [I Temporary Food Facility--Dates of operation from to El Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000 <br /> ❑ Grade A Dairy El Grade B Dairy ❑ Milk Dispenser--Number of Container in Nfulti head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> ILAZARDOUS 1VASTE PROGRAM(2200) i <br /> ❑ hazardous Waste Generator----To ns Generated Per Year ❑ Recycle f Exempt System(2299) <br /> ❑ CRT Offsite I3andlers(2218) ❑ 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) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and P)(ornrs <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotel/hlotel Number of Units ❑ Jail or Exempt Institution---Numbcr of Units <br /> Employee Ifousing(2700) Use Fraplopee Ifousint?/Labor Camp Applicatiorr Fomi <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAF Site ❑ Local MV Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned 111'Site ❑ non-NPL/SEP Cleanup Site ❑RR'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility El Pool ❑ Spa ❑Out of Sen'ice Pool/Spa ❑ Natural Balding Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4 12 1) ❑ 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 /> te <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery M'aste Site ❑ CIA LSludggeandfill <br /> ll Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility El CIA Landfill Sife <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site <br /> fAEDICAL WASTE PROGRAM(4500) <br /> IJ Primary Care El Acute Care El Skilled Nursing 1:1 Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--11 2- I0 ❑ I I -6o---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)(/se PIIS FUD 46-02-003 Rfuc Application Form <br /> (EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> I'ROGR.Mi ELEMENT �( t� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INsrr.Crow# P E"tIT\jALID to ❑ Food Handler <br /> ❑ Check i _ AMOUNT PAID Date 114VOICE it — <br /> ❑ Cash REVIENVED BY ACCOUNTING OFFICE __ Date <br />