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i <br /> _ s - <br /> 4 SAN JOAQUIN COUNTY ENVIRONM.ENTAL HEALTH DEPARTi1IENT <br /> MASTEIMLE RECORD INFOItMAT1UN FORM <br /> ❑New EH Pro aryl at Existing Facility ❑New Eli Program and New Facility <br /> Facility ID Z2 Pro ram Record ID o2 <br /> Facility Address <br /> 9 Z �-7 Al <br /> ti <br /> (Please Check the appropriate description and specify E!M number of units and pertinent information.) <br /> roop PROGRAM(1604) <br /> ❑Restaurant: Stating Capacity Square Footage Food Handlers Course required:- YFs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Veiiicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Mill`Dispenser Number of Containers in Multi-Head Unit <br /> 'Y CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance RecyrlerS(2217) <br /> Tiered Permitting Facility----'- ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CS) <br /> ❑Permit-By-Rule Fixed Unit '❑Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and_Bforms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee lrvgsiag=Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECT! N COt OL(3000) <br /> 13 Environmental Assessment UST-CAP Site ❑Local HW Cleanup Site- 13NPIZEP Cleanup Site 13 UIC Site <br /> ❑Abandoned HW Site ❑moa-NPLISEP Cleanup Site, ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P90I ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR-CONTROL P ROG RAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑ Transfer Station ❑Ag/CanneryWaste Site ❑SludgelAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ' ❑Acute Care ❑ Skilled Nursing ❑Large Generator 0 Small Generator ❑ Limited Ifauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-13 2-10 ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P01SFffD46-02-003 Blue rtnyticadanForm <br /> EMERGEgCY NOTIFICATION FOR THis FACILITY ANWOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT Z S �ry FEE ❑ Surcharge FEE ❑ Other FEE <br /> irismcTOR#G G f PEPMUVALID . to ❑ Food Handler <br /> © Check# AmoUNT PAID Date INVOICE# <br /> ❑ Cash REVMWEn BY AccoUNTING OFFICE Date l <br />