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r -- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME,NT MASTERFTLE RECORD INFORMATION FORM ew EH Program at Exist Facility ❑New Ell Program and New Facility Facilit•ID ` Pro rate Record ID fZ7 .922i Facility Address a f)�9 � /�!► �' � (Please Check the appropriate description and specify sire number of units and pertinent information) FOOD PROGRAM(1600) 1:1 Restaurant: Seating Capacity Square Footage Food handlers Course reguired:. Yrs 11No ❑ ❑ Commissary D Dry storage only ❑with Food Preparation ❑Fending Machines Number of Units ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only 11 Mobile Food Vehicle—Make Vehicle Type Color Registration# License It Sticker# ❑Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility -Dates of operation from to 11 lee 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) IIAZARDOUS WASTE PROGRAM{2200) l" ❑Ilazardous Waste Generator. Tons Generated Per Year ❑Recycle[Exempt System{ 299} ❑CRT Offsite Handlers(2218) ❑Silver Only(7222) ❑Appliance Recyclers(2217) Tiered Pere itfing Facility ❑ Conditionally Authorized(CA) ❑Conditionally Exempt(CE) ❑Permit-By-Rule F' ❑Permit�Rule Household Hazardous Waste 'ABOVEGROUND STORAGE TANK FACILITY(AST) Number of AST 2$31 ( ( J - UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms `�-' HOUSING PROGRAM(2400) ❑HotellMotel Number of Units ❑Jail or Exempt Institution—Number of Units £mploya housing(2700)Use Em to ee Housin /Labor Cam A licafioa Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTR043000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local IiW Cleanup Site. ©NPIJSEP Cleanup Site ❑UIC Site ❑Abandoned RW Site ❑-non-NPLISEP Cleanup Site 0 RNVQCB Cleanup Site -D Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑Pool ❑Spa ❑Out of Service PooUSpa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑Poultry Farm—Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(4 121) ❑Body Piercing(4120) 0 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) L3 Landfill ❑Transfer Station ❑Ag I Cannery Waste Site © 5ludgelAsh Site 13Waste Tire Facility ❑ Compost Facility 13ProcesslRecycle Facility T ❑CIA-Landfill Site © Refuse Vehicles Number of Units ©Dumpsters>20 cu yd--Number of Units ❑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--0 2-10 ❑ l l-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EFID 46-02-403 fllue Application Form EMERGENCY NOTIFICATION FOR Tms FACILITY ANDIOR PROGRAM CONTACT PERSON �c Day Ph Night Ph PROGRAM ELEME'T a U FEE ❑ Surcharge FEE ❑ Other FEE INSrECrOR# PERMITVALID to ❑Food Ilandler ❑ Check# AMOUNT PAID Date INVOICE# ❑Cash REvmwE:ti"sY AccOUNTING OFFICE Date L`