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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASARFILE RECORD INFORMATION FORM <br /> ❑New EH.Prggnm at Existing Facility ®New EH Proam and New Facility <br /> Facility ID O o a Program Record ED q,3 D <br /> Facility Address l .Y scA AAe_ e. N,4cc..,— y61� <br /> (Please Check the appropriate description and specify 1jM number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers:Course required: YES❑ No❑ <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation . ❑Vending Machines.—Number of Units <br /> [IRetail Market—Square footage • 11with Meat Market only ❑Multiple D.e�. ❑Prepackaged Goods Only <br /> ❑Mobile Food Vehicle- Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle 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(20. 00) <br /> ❑Grade A Dalry ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(221 s) ❑ 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 /> Q ABOVEGROUND STORAGE TANK FACILITY(ASI)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A andft forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units -❑Jail or Exempt Institution--Number of Units <br /> Employee Housing(2700)Use Employee HousinglLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site 0 NPL ISEP 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 ❑Pool ❑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(412 1) ❑Body Pierdng(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> E3 Pumper Vehicle—Registration# License# Capacity Vehicle# - <br /> (3 Pamper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill • ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> IR Waste Tire Facility ❑Compost Facdity ❑Process/Recycle Facility ❑CIA Landfill Site <br /> ❑Refuse Vehides.Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility-0 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACTPERSON Day Ph Night Ph <br /> PROGRAM ELEMENTy7�f/7 FEE ❑ Surcharge FEE ❑Other FEE <br /> INSPECTOR# PERMIT VALID -to ❑.Food Handler <br /> IV <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> [ICash REVIEWEDBY AccouNTINGOFnCE Date o <br />