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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIM LNTI] <br /> IIIASTERFILE RECORD INFORMATION FORll1 <br /> I New EH Program at Existing Facility j4ew Ell Progr-am and New Facility_ <br /> Facility Ill AC Pro ram Record ID {--O <br /> Fae ily Address ei ,, 1vc) h� , CA 45�OS <br /> (Please Check the appropriate description and specify size,number of units and peri cnt information.) <br /> F=OOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes El NO El <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑\'ending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food\`chicle--Male 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 frorn to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ hlilk Dispenser--Number of Containers in Multi-licad Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) r <br /> ❑ hazardous Waste Generator— Tons Generated Per Year ❑ Recycle I Eaenrpt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyelers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Pernut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forrrrs <br /> HOUSING PROGRAM(2400) <br /> ❑ IIote"lotel--Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700) Usc Fnrployee flousittZagbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAF Site ❑ Local IBV Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IBV Site ❑ non-NPLJSEP Cleanup Site ❑R\VQCB Cleanup Site ❑ \Fater 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 /> ❑ Poultry Farm Maximum number of birds El 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 /> ❑ Landfill ❑ Transfer Station ❑ Ag(Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑�Faste Tire Facility 11Compost Facility 11 Process(Re cycle Facility ElCIA 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 hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----E] 2- 10---❑ 11 -60----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use Pff;SF[[Dd6-02-003 RlarApplicaliorr Furrrr <br /> EM11[RG[NCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT rE RSON Day PIr Night Ph <br /> PRociILAM1I ELEMENT —/ /[q FEE ❑ Surcharge FEF _ ❑ Other FEF. <br /> INSPECTOR# PER1,111-VALID . to _ ❑ Food handler <br /> [] C1i.ck k 1 _ AMOUNT PAIL) lialc— -- -- 11IVOIcr IF — <br /> ❑ Cash RE%'IEWFDBY ACCOUNTINGOFFICF Date <br />