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SAN JOAQUIN COUNTY E RONMENTAI.,HEALTH DEPART,riENT MASTkjU'ILE RECORD INFORMATION FORM ,ANew EH Prograrn at Existing Facility ❑New EH Pro2m and New Facility Facility ID Program Record ID Facility Address (Please Check the appropriate description and specify lilt,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines:Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple De tfnients. 11 Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration#. License# Sticker# ❑Temporary Food Facility—Dates of operation from to ❑Ice Plant ❑ Special Event —Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) ❑Hazardous Waste Generator Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(22 is) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numberof AST UNDERGROUND STORAGE TANK(USI)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑Iiot&Motel Number of Units ❑Jail or Exempt Institution dumber of Units Employee Housing(2700)Use Employee KousinrlLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONT 000) & ❑ Environmental Assessment ❑UST-CAP Site ❑ Local IIW Cleanup Site ❑NPLISEP Cleanup Site ❑ UIC Site ❑Abandoned 11W Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site aWaste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles.—Numbs of Units ❑Dumpsters>20 cu yd—Number of Units ❑Firm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited IIauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11-60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS E11D i6-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACTPERSON Day Ph Night Ph PROGRAM ELEMENT q 7 4Y b FEE ❑ Surcharge FEE ❑Other FEE INSPECTOR# �Ioi5 PERMITVALID to ❑Food Handler ❑ Check# AMOUNT PAID Date INVOICE ff ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date _7 -- 7 O�)