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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM _ New EH Program at Existing Facility ❑New EH Promarn and New Facility Facility ID Program Record ID f�-oS2 6 l Facility Address 7 -5• Ati r (Please Check the appropriate description and specify size,number of units and pertine t information.) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquareFootage Food Handlers Course required: Yes❑ No❑ ❑ Commissary ❑ Drystorage only ❑with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market--Square footage ❑ with Meat Market only 1:1Multiple Departments 13Prepackaged 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 COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility-----❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) J 11 Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste 04 ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST��. /// "UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee Housine/Labor Cama Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned RW 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 11 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100)_ ❑Tattooing(4121) ❑ 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 ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—NumberofUnits 11Dumpsters>20cuyd—NumberofUnits ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--❑2- IO-----—❑ 11-60----❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 4&02-003 Blue Application Form EMERGENCY NOTI ICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON 1 rU - Day Ph 6 -7— ight Ph PROGRAM ELEMENT 0 FEE ff ❑ Surcharge FEE ❑Other FEE INSPECTOR# PERMIT VALID to ❑Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REvrEwED BY ACCOUNTING OFFICE Date 5 Manerfile Record Pink 48-02-034 10/62003