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SAN JOAQUIN C OUNI'Y ENVi UNNIEN IAL 11EAL'I'li EPA ITYILN'1' - <br /> MASTE IL CORD INFORMATION FORM <br /> New EH Program at Existin Facili ❑New EH Pro ram and ew Facili <br /> Facility 1D Proprai Record I <br /> Facility Address L <br /> (Please Check the appropriate description and specify size•number of units andep rtinent Information.) <br /> FOOD PROGRAM,(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: VES❑ No❑ <br /> • Commissary 0 Dry storage only ❑ with Food Preparation ❑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 /> ❑ Mobile Food Prep Unit-=Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility---Dates of operation from to ❑ tee Plant <br /> ❑ Special Event --:Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000)` <br /> ❑ Grade A Dairy_; ❑ Grade B Dairy ❑ Milk DIspenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ 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 /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B forrns <br /> HOUSING'PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units 0 Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Emnloyee Housing/Labor Cama A„palication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) <br /> • Environmental Assessment ❑ UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br /> ❑ Abandoned HW' Site 0 non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600): <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry''Farm Maximum number of birds 0 Kennel <br /> TATT60BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# 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 0 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 ❑ Common Storage Facility-----O 2- 10-------❑ 11 -60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRA*ELEMEN-r FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMITVALID to ❑ Food Handler <br /> ❑ Check k AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48:02-034 Masterfile Record Pink <br /> 11/18/03 <br />