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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />STERFI <br />MALE RECORD INFORMATION FORM <br />❑ New EH Program of Existing Facility *INcw BH" Program and New Facility <br />Facility m .04' nn x.41 t. Program Record ID"ri �)7 � - 3_ <br />Facility Address 12, O�q W Wat , - <br />(Piease- Check the appropriate description and specify sim number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />D Restaurant: Seating Capacity Square Footage Food handlers Course required; . YEs D No D <br />D Commissary D Dry §forage only D with Food Preparation 08'ending Machines Number of Units - <br />D Retail Market ---Square footage D with Meat Market only D Multiple Departments D Prepackaged Goods Only <br />D Mobile Food Vehicle ----Make Vehick Type Color <br />Registration # License # Sticker # _ <br />D Mobile Food Prep Unit: Make Vel icle Type Color <br />Registration # License # Sticker # <br />D Temporary Food Facility Dates of operation from to <br />13 Special Event --Dates of operation from to <br />DAIRY PROGRAM (2000) <br />D Implant <br />❑ Produce Stand <br />D Grade A Dairy D Grade B Dairy 13 MilkDispenser—Number of Containers in Multi Head Unit <br />COPA D State Facility Surcharge (2399) <br />IIA.ZARDOUS WASTE PROGRAM (2200)' t <br />D Hazardous Waste Generafor. - Tons Generated Per Year D Recycle 1 Exempt System (2249) <br />D CRT Offsite handlers (2219) D Silver Only (1.222) D Appliance Recyclers (2217) <br />Tiered Permitting Facility- D Conditionally Authorized (CA) D Conditionally Exempt (CE) - <br />D Permit ByRule Fixed Unit D Permit -By -Rule Household hazardous Waste <br />D 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 />D AotellMotel ----Nun*" of Units II Jail orExempt Institution Nurnw of Units <br />Employee Housiag (2700) Ilse Enloyee 11ousixr&4or Camp. tpyiicsrtiore Form <br />SITE MITIGATION (2900) UNDERGROUNDINJECTION CONTROL(3000) <br />D Enviroameatat Asstssment D UST -CAP Site D Local HW Cleanup Site• D NPLISEP Cleanup Site ❑ UIC site <br />D Abandoned HW Site D non-NPLiSEP Cleanup Site D RNYQCB Cleanup Site 'D Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility - ❑ Pt►oi D Spa D Out of Service PeoUSpa D Natural Bathing Area <br />VECTOR.COHTROL PROGRAM (4000) <br />D Poultry Farm Maximum number of birds El Kennel <br />TA - 00 BOGY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) D Body Piercing (4120) D Permanent Cosmetics (4122) <br />LJOUiD WASTE PROGRAM (4200) <br />D Pumper Vehicle—Registration# License# Capacity Vehicle•# <br />❑ pumper Yard D Package Treatment Plant- 13 Cktmica! Toilets—Numbs of Units <br />SOUD WASTE PROGRAM (4400) <br />D Landfdl D Transfer Station D Ag I Cannery -Waste Site D Sludge/Ash Site <br />D Waste Tire Facility O Compost Fatality D ProctsslRecyde Facility D CIAJandtill Site <br />D Refuse Vehicles Number of Units D Dumpsters > 20 eu yd Number of Units D Farmatauch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />D Primary Care D Acute Care D SkilledNursuag D Large GeneratorI] Small Generator D Limited Hauler <br />❑ Transfer Station D Veterinary Clinic D Common Storage Facility ----13 2 -10 ❑ 11- 60 —D > 60 b'werators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EMP 46-02-003 BiueAntrtication Form <br />EMERGENCY Noirtt=tca-nON FOR THfs FACILITY ANDIOR PROGRAM <br />�+r .wrT �r nen eniv MV Ph Night Ph <br />PROGRAM E=jajCPERM1TVAUD <br />�i� (� FEE D Surcharge Fse D Other FEE <br />IrrsrEcrOR€1 . to D Food handler <br />D Check # AMOUNTPAID Date INVOICE # <br />D cash Rsvtswsn-ax <br />Avco MUNG OMCs LA Date <br />m9.GIenur, mcam[U r1IIF <br />