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SAIN JOAQUIN COUNT s ENVIRONI IENTAL HEALTII DEPART A-11-EIN ' <br /> NlAS'TERFILE RECORD INFORMATION FOr,,M <br /> ❑New EH Program at Existing facility — `a !dI <br /> ew Eli Program and New Facilil}_ <br /> Facility ID ® � Pr ovram RecoI) _ <br /> Facility Address� 0 <br /> (Please Check the appropriate description and specify size,number of units and Pertinent information) <br /> FOOD PROGRAM(IGOO) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ Mili Food Preparation ❑Vending Machiaes—Number of Units <br /> ❑ Retail Afarkel—Square footage ❑ with bleat(Markel only ❑ Multiple Deparlmcnis ❑ Prepackaged Goods Only <br /> El Mobile Food Vehicle---Make_ Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ mobile Food Prep Uni(—Make Vehicle Type Color <br /> Registration# License# Sticker 4 <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Eveat --Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy, ❑ Grade B Dairy ❑ Milk Dispenser—Number of Container in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS tiVASTE 1'ROGRAhl(2200) i <br /> ❑hazardous`Paste Generator-- Toru Generated Per Year ❑ Recycle/Esenrpt System(2299) <br /> ❑ CRT Offsite Iiandlers(221 E) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered I'ermi(ting facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Pemut-By-Mule Housebold Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGB-01(2300)Use USIA and P rOELrS <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel(lto(el Number of Units ❑ .tail or Exempt Institution Number of Units <br /> Employe,:Ifousing(2700) Use Iimpla y e ffousint'/Labor Camp Application Fomi <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ En-droameatal Assessment ❑ UST-CAP Site ❑ Local MV Cleanup Site_ ❑)`(PLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IM'Site Elnon-NPLlSEP Cleanup Site ❑R)N'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> NumbcrofPools/Spas at Facility ❑Pool ❑ Spa ❑ Out of Scnicc Pool(Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY 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 Vcbicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets I-Jumber of Univ <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Asti Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Plumber of Units ❑ Farm/Rauch Clcanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Carc ❑ Acute Care E1 Skilled Nursing ❑ Largc Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station �1 Veterinary Cliuie ❑ Common Storage hleility-----❑ 2- 10---❑ 11 -60-- ❑ '60 generators - <br /> PUBLIC WATER SYSTEM PROGRAM(=!600) U.sc Pfl`STUM 4G-02-003 Ririe/tt7plira(ion Furrrr <br /> EmCRGENCY t40 T iFICATION FOR Yms FACILITY miDtOR PROGRAPA <br /> CONTACT'MRSON Day Pli Nig.lit Pli <br /> l'RUG(L1n1rLt:�ll,E_i:T�_WV l'eE� —_ �_ —❑ iurc(iar6cl'EE c:2-- ❑ Uttier l'EF. -- <br /> tNSPF.CTOR f �W�� P[_!-1,IIT\rAL1D to ❑ Foul Ilandlcr --- <br /> ❑ t-luck% Ar,I cluo T 1' >) �!.]l�' 111voicr — <br /> [l t'_r• r-•:�f_f)L'. `rL trr.TR' 117FV-G <br /> I I}� -r�'� �;c. t <br />