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SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTER LE RECORD INFORMATION FORM <br /> ❑New EH Program <br /> att�Existing Facil' ❑New EH Program and New Facility <br /> Facilit ID Program Record ID a 9w <br /> Facility Addressjd �an, <br /> N <br /> (Please Check the appropescrip ' a and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(160 <br /> ❑Restaurant: Seatinacity Square Footage Food Handlers Course required:-. YEs❑ No ❑ <br /> ❑ Commissary ❑Drage onl ❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Squotage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicleake Vehicle Type Color <br /> Regin# License# Sticker# <br /> ❑ Mobile Food Prep UakeVehicle Type Color <br /> Regn# License# Sticker# <br /> ❑ Temporary Food FaDat of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dateperation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ rade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge2399) <br /> HAZARDOUS WASTE PROG M(2200) t <br /> Pulazardous Waste Gen ator. 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 /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGF711rousinalLabor <br /> NK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGNK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units 13Jail or Exempt Institution Number of Units <br /> Employ"Housing(2700)Use Ear to a Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site 11 Local HIV Cleanup Site, ❑NPL/SEP Cleanup Site ❑UIC Site <br /> 11 Abandoned HAY Site [3non-NPLISEP Cleanup Site ❑RwQCB Cleanup Site [3Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROG M(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑ Spa ❑Out of Service Peol/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4 ) <br /> ❑ Poultry Farm Maximum nu r of birds ❑Kennel <br /> TATTOO BODY PIERCING PERM HENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ 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 ❑Tra er Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Comp st Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑ Farm/Raach Cleanup Site <br /> MEDICAL WASTE PROGRAM(45 <br /> ❑ Primary Care ❑ Acute Car ❑ Sldlled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROG M(4600)Use PIPS FIfD 46-02-003 Blue Application Form <br /> E ERGENCY NOTIFICATION FOR Tms FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE El SurchargeFEE ' p� ❑ Other FEE <br /> INSPECTOR# E 1T VAL �� to j� �� O ❑Food Handler <br /> 11Check# AmOU1 f PAID Date INVOICE# <br /> 11 Cash REVIEWED BY ACCOUNTING OFFICE Date �� <br />