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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> RECORD INFORMATION FORM _ <br /> MASTI;RFILT; <br /> ❑New Ell Program at Existing Facility &ew Ell Promm and New Facility <br /> Facilit ID (p 1�2n3�' Pro ram Record ID <br /> F acility Address <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 El No El <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 Vchicle---Make Vehicle Type Color <br /> Registration# License N Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vchicle 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 A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS NVASTE PROGRAh1(2200) 1 <br /> 11 hazardous Waste Generator- — Tons Generated Per Year 1:1 Recycle/Eacmpt Sysicm(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 ❑ Pcmtit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGIUNI(2300) Use UST A and B(omrs <br /> HOUSING PROGRAM(2400) <br /> ❑ IlotcUlllotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700) Use Employee ITousim�/ bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAronmental Assessment ❑ UST-CAF Site ❑ Local MV Cleanup Site. ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLJSEP Cleanup Site ❑RtiVQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL IiEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility El Pool 11 spa El out of Sen'ice Poollspa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> El 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 ❑ Transfer Station ❑Ag/Cannery 1Vaste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>2.0 cu yd —Number of Units ❑ Farm[ aoch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El I'rimar)'Care El Acute Care 11 Skilled Nursing ❑ Large Generator El Small Generator 11 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10 ❑ 11 -60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P1f'SF1TD d6-02-003 R1ueApp1ica6on Form <br /> EMERGENCY NOTIFICATION FOR Tttls FACILITY ANOIOR PROGRAM <br /> CONTACT PERSON Day Ph _ Night Ph _ <br /> PROGRANI ELEMENT y 7 YO FEE ❑ Surcharge FEE ❑ Other FEF <br /> Irtsrr:croR# PL."111'VALID to ❑ Food handler <br /> ❑ l lreck K AMOUNT PAID Date It4votcr It <br /> ❑ Cash— R-EVIG\VEDBY -----ACCOUL4T1i:G PPI—E -- Dat,c <br /> at,c _�)/ Z) <br />