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VNew JOAQUIN COUNTY ENVIRQNIYI,�NTAL HL<'ALTIi DIJPARTNENT PAYMENT M-ASTERKLE RECO" NFOlzMA TION FORM RECEIVE[) Eli Program at EzIsfin Facility ❑New EH Program and New Facility APR 1 0 2015 FacilityID Pro ratuRecord ID SAN JOAgUIN COUNTY \. ENt/IROMENTAL Facility Address j, ,i, , c��cn wt�`� 5 ' HEAtTN DEPART MENT (Please Check the appropriate description and specify s�.e number of units and pertinent information), rOOD PROGRAM(1600) El Restaurant: Seating Capacity SquateFootage Food handlers Course re wired:. YFs 11 Nb❑ : i ❑Commissary 17 Dry storage only ❑with Food Preparation 1181'endiug Maehtnes Number of Units []Relail Market—Square footage ❑with Meat Market only ❑Multiple Departments D Prepackaged Goods Only ❑Mobile Food Vehicle--Make VebicleType Color Registration# License# Sticker# ❑Mobile Food Prep Unit--Make VeiiicleTypc Color Registration# License# Sticker# ❑Temporary Food Facility—Dates of operation from to ❑ Ice Plant Q Special Event —Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) ; ❑Grade A Dairy: E3 Grade B Dairy ❑MilkD spenser---Number of Containers in Multi Head Unit GUPA ❑State Facility Surcharge(2399) IiAZARDOUS INVASTE PROGRAM(2200)' i 0 hazardous'Waste Gencrator - Tons Generated Per Year 'e CI Recycle f Exempt System(2299) CRT Offsite Iandlers(2219) ❑Silver Only(2222j ❑Appliance Recyolers(2217). Tiered Permitting Facility 11 Conditionally Authorized(CA) IO Conditionally Exempt(CE) ❑Permit-By:Rule Fixed Unit ❑Permit-lay Rule household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AM,(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B forms HOUSING PROGRAM(2400) [I Hotel/Motel Number of Units 13 Jail or Exempt Institution Number of Units Employee Rousing(2700)Use Employee Xi'orrsiaL2abor Coutp Ayaliver6on Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 0 Environmental Assessment [I UST-CAP Site Q Local HNV Cleanup Site, [3 NPLISEP Cleanup Site Q UIC Site ©Abandoned HW Site ❑non-NPUSEP Cleanup Site D RWQCB Cleanup Site 'Cl`Vater Quality Remediation Site' RECREATIONAL HEALTH PROGRAM(3600) Nurnbcs of Pools(Spas at Facility. ❑Pgol ❑Spa 0 Out of Service Pool(Spa ❑Natural Bathing Area• VECTOR CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETICPROGRAM(4100) fiattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) L1QUtD WASTE PROGRAM(4200) 0 Pumper Vehicles Registration# License# Capacity Vehicle# 13 Pumper Yard ❑Paekage Treatment Plant. ❑Chemical Toilets:Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill Q Transfer Station ❑Ag I Cannery Waste Site ❑Sludge/Ash Site ❑Waste Tire Facility 11 Compost Facility, 11 Process/Recycle Facility ❑CIA Andrdl Site C7 Refuse Vehicles--Number of Units ❑Dumpsters?20 cu y d—Number of Units ❑Farm/ltanch Cleanup Site MEDICAL WASTE PROGRAM(4500) 11 Primary Care D Acute Care ❑Skilled Nursing 13 Large Generator O Small Generator ❑Limited hauler Transfer Station ❑Veterinary Clinic ❑,Common Storage Facility----13 2-to ❑11-60------0>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)use PFVSEIfD 4642-003 BiueApplication Form EMERGENCY HOTIriCATiON FOR THis FACILITY ANDJOR PROGRAM CONTACT PERSON SS Day Ph 2,OQ�—C—YS—`tr Night Ph 'L0G( �' PROGRAM ELEA1EN-r t tb FEE ❑Surcharge FET 11 Other FEE - INSFECTOR PERMIT VALID . _„ o ❑Food handler ❑Check# AMOUNT PAID '• -' / Date INVOICE# ❑Cash ILEVIEWED Blf ACCOUNTING OFFICE Date Ma,�tertilc Record Pink