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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN LN T <br /> F �IASTERFILE RECORD INFORIIIATION FORT <br /> ❑New EH Program at Existing.Facility <br /> G ew Ell Program and New Facility <br /> •I _ <br /> Facilit D 00 0:(F 1 4 0 Pro ram Record ID 1� b <br /> Facility Address -I Lis e - <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1500) <br /> ❑Restaurant: Seating Capacity Square Footage Food handlers Course required: Yes❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ witli Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Tiobile 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 Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑ hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered I'errnitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Pemut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and R(arras <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotel/Dlotei Numbcr of Units ❑Jail or Exempt Institution--Number of Units <br /> Employee IIousing(2700) Use Iirnplopee Ifousintr/Labor Camp Apelication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local MV Cleauup Site ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLJSEP Cleanup Site ❑R\VQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Senice Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO 13ODY 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 /> ❑ Landfill ❑ Transfer Station ❑ Ag I 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 ❑ Small Generator ❑ Limited IIauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----0 2- 10 ❑ 11 -60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use fiI'SFWD 46-02-003 RGrcArJplicaliolr Forret <br /> FMCRGENCY NOTIFICATION FOR Tills FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAnt ELFINIENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> lNsrrcroR# �� �_ PERh11TVALiD to ❑ Food Handler <br /> ❑ Check# AmoijNT PAID Date It7VOICE II <br /> ❑ Cash REVIEWL-D BY Accom4Tlr:G OFFICE Ual� <br />