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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NIASTERFILE RECORD INFOIOIATION FORM <br /> ❑New EH Program at Existing Facility NEew EH Program and New Facility <br /> Facility h) ID X 5.37 3 F <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food handlers Course required:. YEs 11 No ❑ <br /> ❑ Commissary ❑ Dry storage only El with Food Preparation ❑�'endiag Machines—Number of Units <br /> El Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ElMobile 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(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Numbcr of Containers in Muth-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> ftAZARDOUS WASTE PROGRAM(2200) a <br /> ❑Hazardous Waste Generator.-- Tons Generated Per Year 11 Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(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.9 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Iiotet/ilfotel Number of Units El Jail or Exempt Institution Number of Units <br /> Employee I{ousing(2700)Use Employee ffousftr;/ bar Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ElEnvironmental Assessment [IUST-CAPSite 11Local IINV Cleanup Site, El NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑non-NPIISEP 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 11 Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill 13 Transfer Station El Ag/Cannery Waste Site 11 Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Laudfill Site <br /> ❑ Refuse Vehicles—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 Mauler <br /> ❑ Transfer Station ❑veterinary Clinic ❑ Common Storage Facility--E] 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PII'SFKD f6-02-003 Btne Applica[ion F01771 <br /> EMERGENCY NOTIFICATION FORTHIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGF-01ELENIENT `-17410 FEE /I ❑ Surcharge FEE ❑ Other FEE — <br /> INSPECTOR# ��_� PERMITVALID to (013 113 ❑ Food Handler_._ <br /> IJ ch��k to _ A-MOUNT P kID _ Date INVOICE(# <br /> EJ Cash RSVIEWED BY _—— _ACCOM4TII_,OFFICE -- _� '��_Date <br />