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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MSTERFILE RECORD-INFORMATION FORM 1 .2,?QDz PpG5��7 7 7g <br /> ❑New Ell Program at Existing Facility New EH Program and New Facility53 9-:-? -2 7 7 79' <br /> i <br /> Facility IDB Program Record ID <br /> Facility Address h---s,- <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 ❑Pending 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 13 Ice Plant <br /> [I 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 /> H Z RDOUS WASTE PROGRAM(2200)jKji ' <br /> azardous Waste Generator. Torn Generated Per Year LS `Tn5 -❑Recycle 1 Ezempt 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);forms <br /> HOUSING PROGRAM(2400) <br /> ❑HoteUMotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housing-/Labor Camp Applicafioa Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment 0 UST-CAP Site ❑Local HW Cleanup Site. ❑NPLfSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPL ISEP Cleanup Site ❑RNVQCB 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 /> ❑Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) El Body Piercing(4120) 13 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 Waste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA•Laadfrtl Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Firm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4$00) <br /> ❑ Primary Care ❑Acute Care ❑S1:illed"Nursing Large Generator 0 Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility--El 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER_ SYSTEM PROGRAM(4600)Use PHS END 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR rms FACILITY AND/OR PROGRAM <br /> CONTACT PERSON 4 Day Ph Night Ph <br /> PROGRAM ELENIEhT Z2'LO`y EE ❑Surcha a FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID_� to 02 l ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> 0 Cash RMEWEDBY ACCOUNTING OFFICE Date fl �� <br />