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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTER LE RECORD INFORMATION FORM <br /> New Eli Program at Existin Faci ity []New EH Program and New Facility <br /> Facilit ID 2 Program Record ID <br /> facility Address I 14-h <br /> (Please Check the appropriate descrip 'on and specify s-ize,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No ❑ <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 /> ❑ <br /> Temporary Food Facility----<Da s of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operati 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 /> COPA ❑ State Facility Surcharg (2399) <br /> IIAZA OUS WASTE FROG M(2200) <br /> 3KIazardous Waste Ge erator. Tons Generated Per Year <C:5 ❑Recycle I Exempt System(2299) <br /> CRT Offsite Handle (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 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 /> ❑ Hotel/Motel Number of Uni ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Fin to a Housin /Labor Cam A tieation Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment UST-CAP Site ❑Local RW Cleanup Site_ ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned I1W Site non-NPLSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROG M(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(40W) <br /> ❑ Poultry Farm Maximum nt tuber of birds ❑ Kennel <br /> TATTOO BODY PIERCING PER AANENT 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 ❑ Co post Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Un ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(45 ) <br /> ❑ Primary Care ❑ Acute C re ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station 131'eterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ 11-60---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P1VS EIID 46-02-003 Blue Application Form <br /> M[RG[NCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON e Day Ph old 7-9 Might Ph <br /> PROGRAM ELEMENT �2 220 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 14Z_1 PI IT VALID e z< ?-m O to �C �3/ ?�/O [I Food Handler <br /> El # AhI UNT PAI Date B 2 INVOICE# 02� !r� <br /> 0 <br /> 0 Cash REVIEWED B �O ACCOUNTING OFFICE Date <br />