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SAN SOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Y MASURFILE RECORD INFORMATION FORM <br /> B-New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID 14-� :. `t.) Program Record 11) <br /> Facility Address 9-,650 <br /> (Please Check the appropriate description and specify shy number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Prcpamtion , ❑Vcnding Machines.-Number'of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple Depa ❑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 Multi4lead 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 Recyclem(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) O 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.8 forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units ❑Jar?or Exempt Institution--dumber of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL( 000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local RW Cleanup Site ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑ non-NPLSEP 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(4 100) <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 /> 13 Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle 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—❑ 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'S EHD t6-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 17 yy FEE jc� ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# Yy 4> PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 0 <br />