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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTAIENT <br /> NIASTERFILG RECORD INFORMATION FORM _ <br /> iA New EH Program at Existing Facility ❑New EH Progrsm and New Facility <br /> Facility ID F 5 Proram Record ID r7D(b <br /> Facility Addressr�.l <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 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 It <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--Numbcr of Containers in Nfulti-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) I <br /> ❑ hazardous Waste Generator--- Tons Generated Per Year ❑ Recycle/Exempt System(2249) <br /> ❑ CRT Offisite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Couditioually Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Pernut-By-Rule I1ousehold Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and R corms <br /> HOUSING PROGRAM(2400) <br /> ❑ notenlotel Number of Units El Jail or Exempt Institution--Number of Units <br /> Employee Ifousing(2700) Use Fmplopee ffausin&T gbor Camp Application Fomi <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAronmeatal Assessment ❑ UST-CAF Site ❑ Local HW Cleanup Site- ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIIS'Site ❑ non-NPLISEP Cleanup Site ❑RWQC13 Cleanup Site ❑ Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PcoWSpa_s at Facility El Pool 11 Spa [1 out of Sen-ice Pool/Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farm Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> [I Pumper Vehicle—Registration It 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 /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehides—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ElPrimary Care El Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generator 11 Limited Hauler <br /> ❑ Transfer Station ❑ Veterivary Clinic ❑ Common Storage Facility-­11 2- 10 ❑ 11 -60 ---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS F,IID 46-02-003 Rluc Application For-rrc <br /> EMERGENCY NOTIFICATION FOR Tills FACILITY AND/OR PROGRAM <br /> CONTACT PEI:SON Day Ph Night Ph <br /> UROGRAM ELEMENT Wl'k4 0 FEE _� ElSurcharge FEE � 11 Other FEE <br /> INSPECTOR# �aoZ I'ERN111-VALID . to ❑ Food handler <br /> ❑ Ch-_-Ck 9 AMOUNT PAID Date IrlvolcE It _ <br /> ❑ Cash REVtcwFnt{y Accotmrinc Orrlce ____ Date <br />