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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> h1ASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit'M Fit 6()1-1 a3O Prog rain Record ID ,53_ 50E <br /> Facility Address (Zd ' E%ccAAur\ CA 153ao <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary11Dry 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 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(20W) <br /> ❑ Grade A Dairy, ❑ Grade B Dairy ❑ Milk Dispenser—Numbcr of Containers in Multi-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) a <br /> El Hazardous Waste Generator— Tons Generated Per Year 11Recycle/Exempt System(2249) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pcmrit-By-Rule Fixed Unit ❑ Pen-nit-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 /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution----Number of Units <br /> Employee housing(2700)Use Fmplo yee ffoasinz/Labor 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 IIW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas 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(4121) ❑ 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 /> 11 Landfill 11 Transfer Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> 19 Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ P.efuse 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--11 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS F,IfD46-02-003 BlueApplicalion Form <br /> EMERGENCY NOTIFICATION FOR THIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> i <br /> PROGRANt ELENIENT 41140 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTORPERMITVALID to ❑ Food Handler <br /> ❑ Check AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY (A I D ACCOUNTING OFFICE Date I'(� <br />