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SAN JOAQUIN COUNTY ENVIRONME,NTAL HEALTH DEPARTMENT <br /> I NMSTERFILE RECORD INFORMATION FORM <br /> I New EH Program at ExistingFacility New Eli Program and New Facility <br /> Facilif ,ID —/t 061 CS-6, 6q Program Record ID _ t <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No 11 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending 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(2000) <br /> ❑ Grade A Dairy [I Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) a <br /> ❑ hazardous Waste Generator— Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) 1 ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ 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 B jornrs <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenjotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Emptoyee housing(2700)Use Fnrployee Housinc/Labor Camp Application Fomt <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local HIV Cleanup Site. ❑ NPLISEP Cleanup Site ElUIC Site <br /> ElAbandoned IINV Site ❑ non-NPUSEP Cleanup Site ❑R\YQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility El Pool 11 spa [.I Out of Service Pool/Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry 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 /> 11 Landfill 11 Transfer Station 11 Ag/Cannery Waste Site 11 Sludge/Ash e/Ash Site <br /> tA 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/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care 11 Acute Care ❑ Skilled Nursing 11 Large Generator 11 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 PII:SEffl)46-02-003 flue Application For-"' <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> i <br /> PROGRANt ELEMENT LAI 40 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# DJo11 PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date �y INVOICE# <br /> ❑ Cash REVIEWED BY UG W.211111 ACCOUNTING OFFICE /: Date <br />