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_ SAN JOAQUIN COUNTY�wwVIRONMENTAL HEALTH DEPAF. #LENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Pro ram and New Facility Facility IDPro ram Record ID Facility Address T Z 0 0 W" )1 M114f-'<' N (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) C3 Restaurant: Seating Capacity Square Footage Food Handlers Course rem YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged 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 C1 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 CUPA ❑ 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) ❑ Conditional! Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit Household- Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use UST A and B form HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use Employee HousinglLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP 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 El 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(#of units) ❑ Dumpsters>20 cu yd(#or Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) 11 Primary Care IJ Acute Care 1:1 Skilled Nursing ❑ Large Generator 13 Small Generator 13 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 011 -60 ❑ a 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT z FEE ❑ Surcharge FEF ❑ Other FEE INSPECTOR# "#1 YRMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date �� f ' 48-02-034 MASTERFILE RECORD INFORMATION PINK — 11!15!07