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SAN JOAQUIN COUNTY ENVIRONN1LN IAL HLAL'1'H 1)L1"A"R*l'1V1LNT <br /> MASTE CO INFORMATION FORM <br /> ew EH Pro SErn at Existinp Facility ❑New EH Pro ramand New Facilit <br /> Facifit ID <br /> Program Record ID <br /> Facility Address L-1-- <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: YESO No❑ <br /> • Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-Number of Units <br /> ❑ Retail Market----Square footage 0 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 PRocRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility;Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(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) Number of AST <br /> UNDERGROUNDSTORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> Hotel/Motel-------Number of Units Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use EmnJovee HousinP/Labor Camp Analicatton Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> El Environmental Assessment • ❑ UST-CAP Site E3 Local HW;Cleanup Site ❑ NPLJSEP Cleanup Site UIC Site <br /> Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PoolstSpas at Facility ❑ Pool ❑Spa ❑ Out of Service Pool/Spa ❑ 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 /> El Tattooing(4121) 1:1 Body Piercing(4120) 13 Permanent Cosmetics(4122)' <br /> LIQUID WASTE PROGRAM(4200) <br /> ® Pumper Vehicle--Registration# License ti Capacity• Vehicle# <br /> Pumper Yard ❑ Package Treatment Plant. 0 Chemical Toilets-------Number of Units <br /> SOLID WASTE_PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ® Process/Recycle Facility ❑ CIA(Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch 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 ElCommon Storage Facility-----02- 10-------❑ i 1 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PiVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAm*ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> IxsPEETOR# i PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> Masterfile Record Pink <br /> 48=02-034 <br /> 11/18/03 <br />