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w <br /> e <br /> SAM JOAQUIN COUNT1 ISN�'IR_orinCLl`t`l'AL IILA.LTII liLI'Alt7'1111s1ti`l' <br /> 11IASTIERFILE RECORD INFORMATION FORI\I. — <br /> ❑Neer E11 Program al Existiu�Facy _ _�� lievr Eli I'rogram and New Facili(y— <br /> Facilih'ID I'ru ram Record II) <br /> Facility Address ARA A3n <br /> (Please Check the appropriate description and specify s ze,number of units and pertinent information.) <br /> i-OOD PROGRAM(1600) <br /> ❑ Resiaur3ut: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ Mili Food Preparation ❑Vending M3chincs—Number of Units <br /> ❑ Retail Market—Square footage ❑ with Meat Maiket only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make_ Vehicle Type Color <br /> Registration# License# Sticker ff <br /> ❑ Mobile Food Prep Uni(—Make Veliicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dales of operation from to ❑ Iee Plant <br /> ❑ Spe-cial Eyeat --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ bfilk Dispenser—Number of Containers in Mufti-Dead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle/Eiempl 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 ❑ I'cmut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AM(2390) Nun-bcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use USTA and R fomrs <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlotel Number of Units ❑ Jail or Exempt lastitutioa---Number of UniLs <br /> Employee Ifousing(2700) Use Jimpforc e Hovsin&T_.b,r Carrrp Appficafiorr F-Ornl <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAronmeatal Assessment ❑ UST-CAP Site ❑ Local MV Cleanup Site, ❑ rmLlSEV Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IM'Site ❑ non-NPL/SEP Cleanup Site ❑MVQCB Cleanup Site ❑ iVater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number orpoolslSpas at Facility ❑Pool ❑ Spa ❑ Out of Senice Pool(Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm 1-4o_ximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING,PERMAFIENT-COSMETIC PROGRAM(4 100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permaneat Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration rr License# Capacity Vchicle# <br /> ❑ Pumper Yard ❑ Package Treatment Mat ❑ Chernical Toilets I4umber of Units <br /> SOLID WASTE PROGRAM(4400) <br /> Landfill ❑ Transfer Station ❑ Ag f Caanery Waste Site ❑ Sludee/Ash Site <br /> (RkWaste Tire Facility ❑ Compost Facility ❑ ProcessfReeyele Facility ❑ CIA Landfill Site <br /> ❑ refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of UniB ❑ Farnv`I:anch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Trausfer')(alioit ❑ Veterinary Clinic ❑ Comtinon S(arage Facilitl'----❑ 2- 10--F-1 11 -60--- ❑ `60 generators <br /> PUBLIC`NATER S9 STEM PROGRAM(4600)Use f ll'S.MD-IeS-02-M Bfirc Form <br /> IEr.1G2GEl1CY NOTIFICATION FOR Yms FACILITY ,AtmfoR FROGRAM <br /> COiNTACT I'F,ItSO(N Day Ph Night Ph <br /> I'RUG'tC1�l rL:�iEhT � �'L� - ❑ Sur ctrsrge FGE�L_ ❑ Otllcr FEE __---- -- <br /> INSPF.(-TC)iV --34'y I'L•1.1 II1 `'AI_lD ?o_-- ❑ hood handler --- <br /> ❑ i-I cE.i, li�;QQ�j ,y r l'r,r11;11 I1 II I' oI !;fl — -- <br /> ❑ i I -- rr+r 6.7� 11 D JV_ ')Ul,MI!,JOiI'U G " -- -1 �1 � <br /> -= - — - �6 <br />