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SAN JOAQUIN COUNT El`- ZONMENTAL HEALTH DEPAR :NT <br /> MASTE LE h,_,c'ORD INFORMATION FORM <br /> New EH Program at Existing Faci ity ❑New EH Program and New Facility <br /> Facilit ID /L < C C-1 l Program Record ID <br /> Facility Address 83 3 C Y�l --31- <br /> (Please <br /> i(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 onl ❑ 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 /> 11 Temporary Food Facility-----Dat of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operatio from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ rade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge 2399) _ <br /> HAZARDOUS WASTE PROG M(2200) j� l <br /> U—Itazardous Waste Gen ator------------Tons Generated Per Year 02� 11 Recycle/Exempt System(2299) <br /> El CRT Offsite Handlers 2218) ❑ Silver Only(2222) El 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 STORAG TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAG 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 Emplovei Housin /Labor mp 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 /> Number of Pools/Spas at Facility 1:1 Pool 11 Spa ❑ Out of Service Poot/Spa 1:1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(TElPoultry Farm--------Maximum nuof birds ❑ Kennel <br /> TATTOO BODY PIERCING PERENT 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 Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Trans f r Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compo t 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 linic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRA (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EM RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT Z FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# i7Y_I PERM T VALID to ❑ Food Handler <br /> ❑ Check# AMOUN r PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE 2r Date <br /> 48-02-034 Masterfile Record Pink <br /> 10/06/03 <br />