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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />RECORD INFORMATION FORM <br />❑ New EH Program at <br />Facility ID, I N,;g` - Program Record IDI <br />Facility Address gtfj R CA Aw- • Lexi CA 952-46 <br />(Please Check the appropriate description and specify siz number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. Yes ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Vending Machines —Number of Units <br />❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation fr <br />❑ Special Event —Dates of operation from <br />Vehicle Type <br />Color <br />License # <br />Sticker # <br />Vehicle Type <br />Color <br />License # <br />Sticker # <br />to ❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />_ ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />IIAZARDOUS WASTE PROGRAM (2200) jl�-- 4 7aSo Shill Qw+r X1039'6' f <br />Hazardous Waste Generator. Tons Generated Per Year < ❑ Recycle IExempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <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 B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motcl Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Fmployee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local BW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site - ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ P901 ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) - - <br />❑ Poultry Farm—Maximum number of birds ❑ Kennel <br />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4 121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper Vehicle—Registration# License# Capacity Vehicle# <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill <br />❑ Transfer Station <br />❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility <br />❑ Compost Facility <br />❑ Process/Recycle Facility <br />❑ CIALandfill Site <br />❑ Refuse Vehicles —Number <br />of Units <br />❑ Dumpsters > 20 cu yd —Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4$00) <br />❑ Primary Care - <br />❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br />❑ Transfer Station <br />❑ Veterinary Clinic <br />❑ Common Storage Facility—.0 2 - 10 <br />— ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PHS FMD 46-02-003 Blue Anplicaeien Form <br />CONTACTPERSON <br />Day Ph 9-M 365 - 14M Night Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE. ❑ Other FEE <br />INSPECTOR# PERMIT VALID . to ❑ Food Handler <br />❑ CheckAMOUNT PAID Date INVOICE# <br />❑ Cash REVIEWED BY ACCOUN71NGOFFICE Date <br />