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SAN JOAQUIN COUNTY EN' _.ONNIENTAL HEALTH DEPART- `INT <br />NIASTERFILE R_ —ORD INFORMATION FORM <br />New EH Pro am at Existing Facili ❑New EH Pro ram and New Facilitv <br />Program Record ID % L G• S q D 7 y <br />Facilitv ID g <br />Facility Address 'ZgO'+ L �� »-o 47 <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />C1 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No El <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit --Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility -----Dates of operation from to <br />❑ Special Event --Dates of operation from to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ 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 Waste 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 B forms <br />HOUSING PROGRAM (2400) <br />❑ IloteUNlotel------- Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Rousing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl 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 />C1 Poultry Farm Maximum number of birds 11 Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />11 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 />❑ Landfill C1 Transfer Station ❑ Ag / Cannery Waste Site ❑Sludge/Ash Site <br />❑ Waste 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 11 Small Generator ❑Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- ❑ 2 - 10 — --- ❑ 11 - 60 ------ 11 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 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 FEE Lk ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # 1 _6 PERMIT VALID to ❑ Food Handler <br />❑ Check k AMot,NT PAID Date INVOICE # <br />❑ ('ash REVIE \VCU BY ACCOUNTING OFFICE Da[C S < ✓ ('� <br />Masterfile Record Pink <br />