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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH`DEPARTMENT <br /> MAST) RFILE RECORD INFORMATION FORM <br /> ®-flew EH Pro at Existing Facility ❑New EH Program and New Facility <br /> Facility ID Ppr p19b zj Program Record ID `P L¢Lf <br /> F acility Address 5 -4-7n- <br /> (Please Check the appropriate description and specify siz___e number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yrs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending.Machines—Number of Units <br /> ❑ Retail Market----Square footage - ❑with Meat Market only ❑Multipld)4p t beats_ ❑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(2000) <br /> ❑ Grade A Dairy ❑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 NVaste Generator Tons Generated Per Year ❑Recycle/Exempt 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,9 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Emploree Housinz/Labor Camp Application Form <br /> F . <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local HW Cleanup Site ❑NPLISEP 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 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/Cannery Waste Site ❑ Sludge/Ash Site <br /> MWaAe Tire Facility ❑ Compost Facility ❑Process/Recycle 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 ❑ 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 PIES EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACTPERSON Day Ph Night Ph <br /> PROGRAM ELEMENT Z L.O FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# Lt o PERMIT VALID b 5 to�� p ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACcouNTwG OFFICE` Date Is <br />