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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NIASTERFILE RECORD INFORMATION FORIA <br /> I New EH Program at Existing Facility ❑New Eli Program and New Facility <br /> Facilit y ID rA 0 b5 Pro ram Record ID � U <br /> Facility Address gf�TbU �t I)mcA pc ,'-nn <br /> (Please Check the appropriate description and specify sue,number of units and,pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes El No El <br /> ❑ Commissary ❑ Dry 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 Eveut —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-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) a <br /> ❑ Hazardous Waste Generafor— Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pcrmit-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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee llousing(2700)Use Fmploree HousinZ/ bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑ Local I1W Cleanup Site, ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned II`V Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB 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 /> ❑ 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 11 Transfer Station El Ag/Cannery Waste Site El Sludde/Ash Site <br /> FAWaste Tire Facility 1:1Compost Facility ElProcesslRecycle Facility 11 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 hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---E] 2- 10 ❑ 11 -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PHS EHD46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON , 1 Day Ph Night Ph <br /> PROGRAM ELEMENT LAI �1� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# a1�Q PERMIT VALID to ❑ Food Handler <br /> ❑ Check AMOUNT PAID Date INVOICE# <br /> ❑ Cash PEVIEWEDBYV ,l� a ACCOUNTING OFFICE Date <br />