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f <br /> SAN JOAQUIN COUNTY I?NVIRONIMENTAL IILAL'I'Ii DEi'AIZ`I'MLtNT <br /> MASTERFILE R-ECOR.D INFOR-DJATION FORM <br /> ❑New Ell Program al ExistiaR Facility _ f 11 Profirsm and 'o. Facility_ <br /> Facility fD '�� �� Prog am Record ID — PAC <br /> Facility Address 1I 193 1sf-- <br /> (Please Check the appropriate description and specify size,nulirher of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food handlers Course required: 1'Es ❑ No El <br /> ❑ Commissary ❑ Dry storage only ❑ M[li Food Preparation ❑Vending Macbiacs—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 rl Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Eyent —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in hfuld-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGiUM(2200) r <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year Cl Recycle I Esen>pt System(2299) <br /> ❑ CRT OlTsite Handlers (221 S) ❑ Silver Only(2222) : ❑ Appliance Rccyclers(2217) <br /> Tiered Permitting Facility ❑ Conditioually Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Perruit-By-Rule Fixed Unit ❑ Pemut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRARI(2300)Use LISTA and F roris <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotentotel—Number of Units ❑ Jail or Exempt lastitution--Number of Units <br /> Employee Iiousiag(2700)Use Enrnfope e HousitT&Labor Carrip Arpficaeiorr Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> [IEaAronrneae <br /> tal Assssmeat 11 UST-CAP Site El Local Illi' n <br /> Cleaup Site ElNPLISEP Cleanup Site El UIC Site <br /> ❑ Abandoned 111Y Site ❑ noa-NPL/SEP Cleanup Site ❑R�VQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIO14AL HEALTH PROGRAM(3600) <br /> 14umber of Pools/Spas at Facility ❑Pool ❑ Spa ❑ Out of Service PoolfSpa ❑ Natural Bathiag Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds El Kennel <br /> TATTOO 130DY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ I'erruanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration t# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatnicat Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4 100) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> 0�'aste'rire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA landfill Site <br /> ❑Refuse Vehicles—Numbcr of Units — ❑ Dump_ters>20 cu yd—Number of Units ❑ F.ar nfI2.anch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primark'Care ❑ Acute Care ❑ Skillcd Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Cornmon Storage Facility---❑ 2- 10---❑ 1 I -60----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use 1 ffSG111) I6-02-003 Rfuc:dr�licanon F�rrn <br /> EMERGENCY NOTIFICATION FOR TRIS FACILITY ANDIOR PROGRAM <br /> CONTAC1'rEI2SON --- _ Day Ph - ----Night Ph _- --- <br /> I'R0(;R01F,LFI\IF_NT '1740 FEE ❑ Surcharge Fu- ❑ Other rFE <br /> INSPFCTor ,x ,Q Pr_tu I1� \r; L1D . to — ❑ Food handler <br /> ❑ n,-:�t.�; _t:ntotayr ':�It, __ __ r),lc_---- �_ Irn�)lcr� __ _ <br /> ❑ C3;h Pf.',,IG'+;gr,rt',' — i,i.rClri:ri�; ;(�rI=JCF AWS T)aIC O-- -- — — <br /> �-- .��#— <br />