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SAN JOAQUIN COUNY I ,RONMENTAL HEALTH DEPAI_ iENT <br /> MASTS E RECORD INFORMATION FORM <br /> ew EH Pro am at Existing Fa ili ❑New EH Program and New Facility acilit ID Pro ram Record ID <br /> Facility Address f-j J�)DYI7 - <br /> (Please Check the appropriate descri tion 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 ❑ <br /> ❑ Commissary ❑ Dry storage o ly ❑ 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-----Da es of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operatio i from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ 3rade B Dairy Cl Milk Dispenser---Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharg (2399) <br /> Hi4AROUS WASTE PROG M(2200) <br /> azardous Waste Gen rotor------------Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facilit ------------------❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAG TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAG TANK(UST)PROGRAM(2300) Use UST A and B forins <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution------Number of Units <br /> Employee Housing(2700) Use Em toe Housin /Labor eamp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP 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(40 0) <br /> ❑ Poultry Farm--------Maximum num er of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERM NENT 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 o Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfe Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compos Facility ❑ Process/Recycle Facility ❑ 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 C inic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRA (4600)Use PIVS EHD 46-02-003 Blue Application Form <br /> EME GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Gv- _ Day Ph Night Ph <br /> PROGRAM ELEMENT�0 c�� EE 00 ❑ Surchar a FE ❑ Other FEE <br /> INSPECTOR# lel V�,�C� PERMIT VALID to �r?i 3 7 (/ 11 Food Handler <br /> 11 Check# AMOUNT AID Date ✓ J INVOICE# <br /> 11 Cash REVIEWED BY 1 rj 4_:3 ACCOUNTING OFFICE Date 31 <br /> 48-02-034 PC—,� /� J 0 (3 <br /> 10/6/2003 <br /> �} 1 (J asterfile Record Pink <br />