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SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTH'DEPARTMENT MASTI RIME RECORD INFORMATION FORAI . ❑New EH Pro at Existing Facility ONew EH Proum and New Facility Facili ID Program Record ID C d `a Facility Address (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No❑ ❑ Commissary ❑Dry storage only ❑ with Food Preparation , ❑Vending Machines—Numbef of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple:I>epatfnients. ❑Prepackaged Goods Only ❑ Mobile Food Vehicle-=—Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration#. License# Sticker# ❑Temporary Food Facility—Dates of operation from to ❑ Ice Plant ❑ Special Event —Dates of operation from to 11 Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑Grade B Dalry ❑Milk Dispenser Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HA7.ARDOUS WASTE PROGRAM(2200) ❑Hazardous Waste Generator Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard 11Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑i�andfdl - ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ire Facility , ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site e ides.—Number of Units ❑Dumpsters>20 cu yd---Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIES EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 30 FEE <:�5 ❑ Surcharge FEE -- ❑ Other FEE INSPECTOR# PERMIT VAL16 23o D$ 7 to �P�3� Ql �7 ❑Food Handler ❑ Check# AMOUNT PAID Date INVOICE# / ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 6(-3D/Q�