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r <br /> SAN JOAQUIN COUNTY ENVIRONIIMEN'I'AL HEALTII DEI'ARTNI ENT <br /> _ NIASTERFILE RE CORD INFORIIIATION FORM — <br /> KNew E-ll Program at ExistiaR Facility ❑Ncv, Elf Promm and Ne•,s Facility_ <br /> Facility IDrani Record ID <br /> Facility Address 5L[+73Pr he✓ e� - <br /> (Please Check the appropriate description and specify sire,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 ❑Wending Alachiaes—Number of Units <br /> ❑Retail Market—Square footage ❑ with 14cat Market only ❑ Multiple Depailments ❑ Prepackaged Goods Only <br /> ❑ Alobile Food Vehicle--Make Vehicle Type Color <br /> Registration 9 License g Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration ff License 4 Sticker <br /> ❑ Temporary Food Facility—Dates of operation from to IJIce I'lant <br /> ❑ Special Event —Dates of operation from to ❑ Frodace Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Mulu-Bead Unit <br /> CUPA ❑ Slate Facility Surcharge(2399) <br /> IIA?ARDOUS\VASTE PROGRAANI(2200) 1 <br /> ❑hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle IExempt System(2299) <br /> ❑ CRT Offsite handlers (2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-lZule Fixed Unit ❑ Pcmut-By-Rule household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)I'ROGRAM(2300)Use UST A acrd F(or-urs <br /> HOUSING PROGRAM(2400) <br /> ❑ Hote"lotel Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Eetployee housing(2700) Use 1--mplalyz ffousiff&T abor Camp Applica[inn Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> [IEnAronmeatal Assessment ❑ UST-CAP Site El Local II 'Cleanup Site 11NPLfSEP Cleanup Site F1 UIC site <br /> ❑ Abandoned 1BY Site ❑ non-NPLISEP Cleanup Site ❑R«'QCB Cleanup Site ❑ Water Quality Remediation Site. <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility_ El Fool 11Spa El out of Scnice PoollSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRARI(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4 120) ❑ renuanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—RegiAration i# License 9 Capacity Vehicle P <br /> ❑ Pumper Pard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery 1N'aste Site ❑ Sludge/Ash Site <br /> ,KWaste Tire Faeitity ❑ Compost Facility ❑ Fro cesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dump_ters>20 cu yd —Number of Units ❑ Farm/Rzach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4 500) <br /> El PrimaryCare El Acute Care 11 Skilled Nursing El Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ f_omroon Storage Facility---❑ 2- 10---❑ 11 -60 ---❑ = 00 generators <br /> PUBLIC WATER SYSTEM PIROGRAPA(4600) UscIIISF111) 1L42-00.3 Fvi'm <br /> ErACRGENCY NOTlFtCATIOU FUR Tms FACILITY ANDIOR PROGRAM <br /> CON TACT•PFRSO I'll Day I'll Night Ph <br /> I'R0GR_uMELFMF-N-14021 0 1E% _ ❑ SurchargeFer t ❑ OtlicrFFE — <br /> IivsrrcT0R,1 o2eSo2Cj I'1:1.11n V,,�LID to _ ❑ Food handler <br /> ❑ rhrck. ,, l;%lc tui.tr.l',>au Date Irnou r:a <br /> ❑ Ca,t Rr.' rorr-pis[ i,:'ctn;rn:,c-Uricr _____- <br />