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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID 001 0 3 C) b Program Record ID�q�� Facility Address I 1 3 Dy C. 3'46,4 f- PD (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: 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 ❑ Ice Plant ❑ Special Event -- Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy 11 MilkDispenser---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) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST — UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) El HoteLlMotel-------Number of Units ❑Jailor Exempt Institution --Number of Units Employee Housing (2700) Use Emploeee Housin lLabor Camp 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 HW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool 1:1 Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM (4000) C1m Poultry Farm--Maximunumber of birds El Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration # _ ❑ Pumper Yard License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station 11 Ag / Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑Large Generator ❑Small Generator ❑Limited Hauler ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---- ❑ 2 - 10 ---- - ❑ 11 - 60 ------ 11 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Day Ph Night Ph CONTACT PERSON PROGRAM ELEMENT 4 1 U FEE_ INSPECTOR# PERMIT VALID ❑ Check # A_NIOUNT PAID _ ❑ Cash REVIEWED BY ❑ Surcharge FEE to Date ACCOUNTING OFFICE ❑ Other FEE ❑ Food Handler INVOICE # Date li li Masterfile Record Pink 48-02-034 10/6/2003