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-- <br /> - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT <br /> RECORD INFORMATION FORM <br /> 11 New EH Program at ExistingFacility ew EH Program and New Facility JUN 0 $ Z0 <br /> /1 Pro ram Record IDC `;L �' 0&4' ENV�R 49 <br /> FacilityID /¢ D lG' p Q+�IA�E�T <br /> Facility Addresst �^/- i � S� G �.5�7�oE�M�r/S�j���E�SrH <br /> (Please Check the appropriate description and specify size. number of units and pertinent inf rmation.) " <br /> FOOD PROGRAM(1604) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No❑ <br /> ❑ Commissary ❑Drystorage only ❑with Food Preparation ❑Fending 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---Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade AD ilry ❑Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) 1 <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I 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 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 Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housixe/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ' [3 NPLISEP Cleanup Site ❑UIC Site <br /> 11Abandoned IIW Site ❑non-NPLISEP Cleanup Site [3RWQCB 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 Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm—Maximum number of birds ❑Kennel <br /> j�x�t()O BODY PIERCIG PERMANENTCOSMETICPROGRAM(4100)tooing(4121) [3 Body Piercing(4120) Permanent Cosmetics(412 2) <br /> (QUID 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/Cannery Waste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA•Landfill Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd----Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care . ❑Acute Care ❑ Skilled Nursing ❑Large Generator Q Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility—Z] 2-10 ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePWSEHD 46-02-003 Mue Application Form <br /> EMERGENCY NOTIFICATION EOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON ' S Day Ph 03!� 9'2-9, Night Ph <br /> PROGRAM ELEMENT 4 l 21 (Z2FEE ❑ Surcharge FEE'. ❑ Other FEE <br /> INSPECTOR# QgW PERMITVALID to 11 Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWEDBY 3?— t ACCOUNTING OFFICE Date <br />