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SAN JOAQUIN COUNTY ENSRONNIENTAL HEALTH DEPART FNT <br /> iVIASTERFILE ORD INFOR.`IATION FORM <br /> ❑ New EH Pro am at Existing Facility New EH Program and New Facilit <br /> Facilit ID (�0 (��� Program Record ID S -7 <br /> Facility Address I ;?. N <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 /> ❑ Temporary Food Facility-----Dates of operation from to 11 Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> [I 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 /> ❑ Hazardous Waste Generator------------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 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 Housin,e/Labor Camp Application Forin <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment ❑ UST-CAP Site 13 Local HW Cleanup Site ElNPL/SEP Cleanup Site 11 UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB 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 /> C1 Poultry Farm- Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> El Pumper Yard 0 Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill 13 Transfer Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility 11Process/Recycle Facility 11 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) ENVIRONMENTAL HEALTH <br /> ❑ Primary Care 1:1Acute Care ❑ Skilled Nursing ❑ Large Generator DEPARTMENT NO LONGER <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2 w <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PFVS EHD 46-02-003 Blue Application FoINSPECTS WASTE TIRE <br /> r <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/Oi FACILITIES. It is a State run <br /> CONTACT PERSON '' LL Day Ph program effective 7/1/2017. <br /> PROGRAM EL''F'`t//EN��T//q_7'+O FEE ❑ Surcharge FEE ❑ Other FEE <br /> I.NSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# ANIOUNT PAID Date INVOICE# <br /> 11 Cash REVIEWED By <br /> ACCOUNTING OFFICE Date GC ( 0 <br /> Masterfile Record Pink <br /> -02-034 <br /> I IiI8/03 <br />