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VNew <br /> JOAQUIN COUNTY ENVIRQNIYI,�NTAL HL<'ALTIi DIJPARTNENT <br /> PAYMENT <br /> M-ASTERKLE RECO" NFOlzMA TION FORM <br /> RECEIVE[) <br /> EliProgram at EzIsfin Facility ❑New EH Program and New Facility APR 1 0 Z(!15 <br /> FacilityID <br /> Pro ratuRecord ID SAN JOAgUIN COUNTY <br /> \. <br /> HEN <br /> V' <br /> Facility Address j, ,i, , c��cn wt�`� 5 ' HEAtTN DEPART <br /> MENT <br /> (Please Check the appropriate description and specify s�.e number of units and pertinent information), <br /> rOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity SquateFootage Food handlers Course re wired:. YFs 11 Nb❑ <br /> : i <br /> ❑Commissary 17 Dry storage only D with Food Preparation 1181'endiug Maehtnes Number of Units <br /> []Relail Market—Square footage O with Meat Market only ❑Multiple Departments D Prepackaged Goods Only <br /> ❑Mobile Food Vehicle--Make VebicleType Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit--Make VeiiicleTypc Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> Q Special Event —Dates of operation from to OProduce Stand <br /> DAIRY PROGRAM(2000) ; <br /> D Grade A Dairy: E3 Grade B Dairy D MilkD spenser---Number of Containers in Multi Head Unit <br /> GUPA ❑State Facility Surcharge(2399) <br /> IiAZARDOUS WASTE PROGRAM(2200)' i <br /> O hazardous'Waste Gencrator - Tons Generated Per Year 'e CI Recycle f Exempt System(2299) <br /> CRT Offsite I3andlers(2218) ❑Silver Only(2222j ❑Appliance Recyolers(2217). <br /> Tiered Permitting Facility O Conditionally Authorized(CA) O Conditionally Exempt(CE) <br /> D Permit-By:Rule Fixed Unit ❑Permit-lay Rule household Hazardous Waste <br /> O ABOVEGROUND STORAGE TANK FACILITY(AM,(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use US'I'A and B forms <br /> HOUSING PROGRAM(2400) <br /> [I Hotel/Motel Number of Units D Jail or Exempt Institution Number of Units <br /> Employee Rousing(2700)Use Employee Xi'orrsiaL2abor Coutp Ayaliver6on Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 0 Environmental Assessment [I UST-CAP Site O Local HNV Cleanup Site, [.1 NPLISEP Cleanup Site Q UIC Site <br /> O Abandoned HW Site ❑non-NPUSEP Cleanup Site C1 RWQCB Cleanup Site 'Cl`Vater Quality Remediation Site' <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Nurnbcs of Pools(Spas at Facility. O Pgol ❑Spa 0 Out of Service Pool(Spa ❑Natural Bathing Area• <br /> VECTOR CONTROL PROGRAM(4000) <br /> 1:1 Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETICPROGRAM(4100) <br /> fiattooing(4121) O Body Piercing(4120) O Permanent Cosmetics(4122) <br /> L1QUtD WASTE PROGRAM(4200) <br /> 0 Pumper Vehicles Registration# License# Capacity Vehicle# <br /> O Pumper Yard 13 Paekage Treatment Plant. ❑Chemical Toilets:Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> O Landfill Q Transfer Station O Ag I CanneryWaste Site O Sludge/Ash Site <br /> D Waste Tire Facility 11 Compost Facility, 11 Process/Recycle Facility ❑CIA Andrdl Site <br /> C7 Refuse Vehicles--Number of Units ❑Dumpsters? <br />