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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MAS01,* .E RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility , Mew EH Program and New Facility <br /> Facility ID 6 0 l(p t f. ::. .. : Program Record ID O�5Y 57, <br /> Facility Address <br /> (Please Check the appropriate description and specify jim,number of units and pertinent information-) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square 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 ❑Multiple:D`epaI�nieuts. ❑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 Dalry ❑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(22 18) ❑ 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/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Ilousinp/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) Zi <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local HW 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 ❑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 /> E!Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑CIA Landfill Site <br /> ❑ Refuse Vehicles.—Number of Units ❑Dumpsters>20 cu yd----Number of Units ❑Firm/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 PIVS EffD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT Lt q d FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# L(.b 1-t5 PERMIT VALID 3o/DS to 00 ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> Cl cash REVIEWED BY ACCOUNTING OFFICE Date Ela0 pJ <br />