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SAN JOAQUIN COUNT``ENVIRONMENTAL HEALTH DEPARTMENT <br /> 117ASI'ERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Exis(ig Facility 4MILew EH P'rogr'am and New Facility <br /> Facilitti' D 0 d 14 31I'rograrn Record ID S5 Z <br /> o � 3� <br /> Facility address 151 Do e— A, . <br /> (Please Check the appropriate description and specify size,number of units and Pertinent information.) <br /> FOOD PROGRAM(160 0) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vendinb Machines—Number of Units <br /> ❑ Retail!Market—Square footage ❑ with Mcat Market only ❑ Multiple Departments ❑ 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 I" <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-Bead Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> IiA7–aRDOUS WASTE PROGRAM(2200) I <br /> ❑ Hazardous Waste Generator 'Eons Generated Per Year ❑Recycle f Exernpt System(2299) <br /> ❑ CRT Offsite,Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility C]Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pernit-By-Rule F-i(ed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUTID STORAGE TANK(UST)PROGRAM(2300)Use UST A and B(arms <br /> ROUSING PROGRta_ l(2400) <br /> ❑ Ilotel/1`iotel Number of Units ❑ Jailor Exempt Institution Number of Units <br /> E'Mployee Ifousing(2700) Use F-mployee LfausinelLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIAV Cleanup Site. ❑NPLlSE?Cleanup Site ❑ UIC Site <br /> ❑ Abandoned 111YSite ❑ non-NPL/SEP Cleanup Site ❑RiVOCB Cleanup Site ❑lVater Quality Remediation Site <br /> RECREATWIAL HEAL i H PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ root ❑ Spa ❑ Out of Senice Pool/Spa ❑Natural Bathing Area <br /> VECTOR COIhI T ROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) rr-11 <br /> ❑ Tsttaoing(4121) 11 Body Piercing(4120) FJ Perm2nent Cosmetics(4122) <br /> LIQUID WASTE PROGRAFA(4200) <br /> F-- hamper 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 NVaste Site ❑ Sludge/Ash Site <br /> .V!iVaste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Unite ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farmfromch 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 ❑ I I-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Usc PJf S F,fID A6-02-003 Illuc Application Form <br /> Eh1ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT rERSON Day Ph Night Ph <br /> I'r0CEL01 ELEMCNT 417110 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSrECTUIt# PER1,11T VALID to ElFood Ilandlcr <br /> ❑ Chtcl,; AMOUNT PAID Date _ 11TVOICE-# <br /> ❑ Cash 1',Z",'!F'.'ED BY Acccm mi'J OFFICE <br />