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SAN JOAQUIN COUNTY ENVIROW ENTAL HEALTH DEPARTMENT <br /> NIASTERFILF RECORD INFORII'IATION FORM <br /> ❑New Ell Program at Existiag,Facility lew Ell Program and New Facility <br /> Facility ID Pro ram Record Il) <br /> Facility Address q l j 4 c zf 4ble <br /> (Please Check the appropriate description and specify size,number of units and pertinent informatYSn.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food IIandlers Course required: YES ❑ No ❑ <br /> [] Commissary ❑ Dry storage only ❑ witlr 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 Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make_ Vehicle Type Color <br /> Registration# License# Sticker# <br /> El Temporary Food Facility--Dates of operation from to El ice Plant <br /> ❑ Special Event --Dates of operaiion from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) I <br /> ❑ hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility El Conditionally Authorized(CA) El Conditionally Exempt(CE) <br /> ❑Penut-By-Rule Fixed Unit ❑ Pemut-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(arms <br /> ROUSING PROGRAM(2400) <br /> ❑ noteUDlote] Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use hmploree IfousinclLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local I1W Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned II`V Site ❑ uou-NPIJSEP Cleanup Site ❑RIVQCB 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 /> ElPoultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle tf <br /> ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> _Waste Tire Facility ❑ Compost Facility ❑ Pro cess/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cuyd —Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Ilauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facilil)•---El 2-10--❑ 11 -60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) UscPIt.SF11D46-02-003 BlucApplicarion Form <br /> EmERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PRoGILANI ELFr)�IENT _ FEE_ ❑ Surcharge Fee El Other FEE <br /> INSPECroR# ,_xf'- PEKNID-VALID to ❑ Food Handler <br /> ❑ Clieck AMOUNT PAID Date INVOICE# _ <br /> ❑ Cash RF_VIEwED BY _ ACCOUNTING OFFICE____ - Date �e <br />