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SEP-1,6-2008(TUE) 13; 54 Proactive Northern Container (FAX) 12099480142 P. 003/003 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL 11EALTH DEPARTMENT <br /> MASTERML'S RL"CORIS INFOR YL6.11ONNFFO�RM <br /> 11 New EH Program at Ezistiu Facility RrN`cw EH Propratn and New Facility <br /> Facility)D a Pro ram Record ID <br /> Facility Addres2 ._� � u3`-3 £• Vemo�, S 5"C—QC �i O J C'A. 9S�/5� <br /> (Please.Check the appropriate description and specify dw.number of units and pertinent information.) <br /> r00D PROGRAM(1600) ' <br /> ❑Restaurant• Scatiog Capacity Square Footage Food Handlers Course rcauired:. Yes❑ N60 <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation [Wending Machina-Number ofUnits <br /> ❑ Retail Market---Square footage 0 with Meat Market only Q Multiple Departments ❑Ptcpackagcd Goods Only <br /> i ❑Mobile Food Vehicle—Make Vehicle Typc Color <br /> Registration# License# Stickrr 11 . <br /> ❑Mobile Food Prep Unit Makc VeNcleType Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility----Bates of operation from - to ❑ Ice Plant <br /> 13 Special Event --Dates of operation from to 13 Produce shwa <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade ADaly ❑ GradeBDalry ❑MllklDispcascrNumberofCoutaina5inMulti-tlmdUnit <br /> cuPA ❑Shtc Facility Sur'chargo(2399) <br /> HAZA�FDOUS WASTE PROGRAM(2200) 1 l <br /> VHarardous Waste Generator Tons Generated Per Year Recycle/Exempt System(2299) <br /> ❑ CRT Offsitc Handlers(2218) ❑ Silver Only(2222) :1 ❑Appliance Recyclers(2117) <br /> Tiered Permitting Faea'I[ty ❑Conditionally Authorized(CA) Q Conditionally Exempt(CL) <br /> Q Pcrmit-By-Rule Fixed Unit ❑Petmit-By-Rule Household Hazardous Waste ; <br /> ❑ABOVEGROUNDSTORAGE TANK FACILrrY(AST)(2390) NumberofAST <br /> .UNDERGROUND STORAGE TANK(UST)PROGRAM(7300)Use LM. A and S(orae' <br /> HOUSING PROGRAM(2400) . <br /> ❑Sotcymotel—Number ofUnits _❑Jail or Exempt Institution Nwttbaorunits . <br /> Employee Housiac(2700)Use a Plovee V, AppRcatiort Farm <br /> SITE MI'1'tGATION(7900) UNDERGROUND INJECTION CONTROL(3000) <br /> .❑Environmental Assessment Cl UST-CAP Site ❑Local HW Cleanup Site. : ❑NPLSEP Cleanup Site Q UIC Site <br /> ❑Abandoned HW Site ❑non-NPUSEr cleanup Site Q RWQCD Cleanup Site ❑Water Quality Remediation Site <br /> ECREATIONAt_ ALTH PROGRAM(3600) <br /> Nutulxr of PoOIVSPas at Facility" ❑Pool ❑Spa Q Out of Scrvicc PooNSpa ❑Natural Bathing Arca <br /> VECTOR CONTROL.PROGRAM(4000) <br /> [l roultry Farm----?,12.xximumnumber of birds ❑Kcnmel <br /> TATTOO BODY PI RCtNG PERMANENT COSMETIC PROGRAM(4100) .' <br /> ❑Tattooing(4121) ❑Body 111creing(4120) ❑Perntment Cosmetics(4122) <br /> I�OUID WASTEPROGRAM(4200) <br /> 13Pumper Vehicle-Rcgismatiom# License 9Capacity Vehicle-4 <br /> ❑ Pumper Yard ❑Package Treatment Plant, ❑Chemical TolletsNumber of Units <br /> . SOLID WAS-17 PROGRAM(4400). _.. ._ _... .. . . .. <br /> ❑Landoll- ❑Transfer Station ❑Ag I Cannery Waste Site ❑SludgelAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Pruces mcgcleFacility ❑ CIA•LandtillSite <br /> ❑Refuse VehiclesNumber of Units ❑Dumpsiers>20 ea yd---Number of Units ❑FarlNRaach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500)- - <br /> --❑-i'r(nury'Care---OAeuteCare "" `-❑-5k111ed'Nuraing "-E3'LargeGcncr3tor' ---:-13"5mallGenerajor- -,Limited-ITauler --- __... <br /> Q Transfer Station ❑Veterinary Clinic ❑ Common Storage Faciiity—❑2-10-----Q 11-60----Q>60 generators <br /> PURLIC WATER SYSTEM PROGRAM(4600)UserP f1$r 16-02-003 R[ur.Arnl:crctioa Form <br /> EMEROENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Pit Night Ph <br /> PROCRAMLLF,MENT 02 L FEE ❑SurekargeFrx,. ❑ Other FEE <br /> INsrvcroa# 'l PERMIT VALID . I-C—d 8� to t12 X31'!Y 15 C7 Food Handler <br /> EI Cl,eckII .AMOUNT PAID ►��" � Date INVOICEff <br /> Q Cash 10EYIEwESi nY /(� I��tn ACCOUNTING OHICe Date Q <br />