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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 111ASTERFILE RECORD INFORMATION FO101 <br /> KNew EH Program at Existing Facility acw EIl Program and Nen'Facility <br /> Facility ID EA�j('7 I( t Program Record <br /> Taeility Address .F��.:Z C�a�r .. l�� <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: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation El 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 /> ❑ I4Iobilc Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ElTemporary 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 ❑ Grade B Dairy ❑ Ittilk Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IlAZARDOUS\VASTE I'ROGRAh1(2200) 1 <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Perruit-By-Rule Fixed Unit ❑ Pernut-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 B(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlotel Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee Ifousing(2700)Use Employee Ifousin�,ILabor Carne Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ En`ironmeatal Assessment ❑ UST-CAF Site ❑ Local IIW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned 1IW Site ❑ non-NPI./SEP Cleanup Site ❑R\NrQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ On(of Senice Poollspa ❑ 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(4121) ❑ Body Piercing(4 120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle ti <br /> ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludgc/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ 1'rocess/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units — ❑ Dumpsters>20 cu yd --Number of Units ❑ Farriaauch 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----El 2- 10---❑ 11 -60----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Usc PIISE11D.16-02-003 BlueAprlicaeiort Furm <br /> EMERGENCY NOTIFICATION FOR Tills FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PRoc;RANI ELEMENT '114iC FEE ❑ Surcharge FEE ❑ Other FEE <br /> lNscecrop, PEKNIII-VALID _ to ❑ Food Handler <br /> ❑ Check k AMOUNT PAID Date _ It.VOICF.It <br /> ❑ Cash REVIEWED BY ACCOUNTING,OFFICE <br />