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SAN JOAQ JIN;COUNTY ElvowIRONNIENTAL HEALTH DEPAR'\EENT <br /> MASTERFH.E RECORD INFORMATION FOWA <br /> New EH Program at Existing g Facility - ❑New EH Program and New Facility <br /> Facility ID Pro gramRecordID QO S ;t 3 7 <br /> Facility Address �-�\ 6,� <br /> (Please Check the appropriate description 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 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 /> [I Temporary Food Facility-----Dates of operation from to 1:1 Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit _ <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> R'Hazardous Waste Generator------------Tons Generated Per Year LS —�S 13 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 Fired 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 Jailor Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp 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 PROGRAM(3600) <br /> ❑ Pool 11 Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) El Permanent Cosmetics(4122) <br /> El Tattooing(412 1) ❑ Body'Piercing(4120) <br /> LIQUID WASTE pROGRAM(4200) CapacityVehicle# <br /> ❑ Pumper Vehicle--Registration# License# P Y <br /> ❑ Pumper Yard - ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) El Slud etAsh Site <br /> ❑ Landfill ❑ Transfer Station 11 Ag/Cannery Waste Site g <br /> ❑ Process/Rec cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility y ❑ Fartn/Ranch Cleanup Site <br /> 11 Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu rd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----02- 10------❑ 11 -60-11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use MYS EHD 4602-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph h <br /> CONTACT PERSON <br /> other FEE <br /> PROGRAM ELEMENT <br /> � 7 FEE a'� [ISurcha; a FEE [I❑ Food Handler <br /> INSPECTOR# KbceF% PERMITVALID "11%10A�Dy t0 <br /> AMOUNT PAID /11vlC%� <br /> . D Date INVOICE#c7 <br /> ❑Check# Date G d <br /> [ICash REVIEWED BY ACCOUNTING OFFICE <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 101612003 <br />