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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM-NT <br /> MASTERFILE R )RD INFORMATION FORM <br /> ❑New Ell Program at Existing Facility ❑New Ell Program and New Facility <br /> Facility I (c3L' Pro ram Record ID -o 535- 3 <br /> ,acility Address C) l- <br /> (Please Clieck the appropriate description and specify s_ize,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Ilandlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending Machines—Number of Units <br /> ❑ Retail Alai-Let--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 (2040) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ milk Dispenser--Number of Containers in Multi-Iiead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS IVASTE PROGRAM(2200) <br /> ❑ hazardous NVaste Generator----Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Ilandlers(2218) ❑Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Perirut-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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> Hotd(htotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> A)loyee IIousing(2700)Use Employee IlousinzTabor Camp Applicaliou Form <br /> dTE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAI'Site ❑ Local IIW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑Abandoned IIW Site ❑ non-NPLISEP 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 Bathiug Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4)21) ❑ Body Piercing(4 120) ❑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 t Cannery Waste Site ❑Sludge/Ash Site <br /> Waste Tire Facility 11 Compost Facility Precess/Recycie Facility ❑ CIA•,Landfill Site <br /> T11 <br /> Refuse Vehicles—Number of Units ❑Dumpsfers>20 cu yd—Number of Units ❑FarnuTanch Cleanup Site <br /> MEDICAL WASTE PROGRAM.(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator Q Small Generator ❑ Limited Ilauler <br /> ❑ Transfer Station ❑.Veterinary Clinic ❑ Common Storage Facility--0 2- 10--❑ 11-60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PII'SEIlD 46-02-003 BlueApplicalion Form <br /> EMERGENCY NOTIFICATION FOR TRIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> )GRAM ELEMENT O FEE ❑ Surcharge FEE ❑ Other FEE <br /> LECTOR# r%/ PERMIT VALID to ❑Food handler <br /> ❑ Cf}eck# 1 AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY i O ACCOUNTING OFFICE Date 7- /(� <br />