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SAN JOAQUIN COUNTY EIRONMENTAL HEALTH DEPA�ZENT <br /> MASTERFlu RECORD TNNFORMATION FORM <br /> New EH Pro am at Existiu Facili <br /> ❑New EH Pro am and New Facility <br /> Fa it <br /> ID t` 3 � Pro ram Record ID _ (}S 2 <br /> FBIL ES <br /> Facility Address --4-4c� t�oia�s c-i <br /> (Please Check the appropriate description and specify size,number of units and ertineri#information.} <br /> FOOD PROGRAM(1600) <br /> -..-❑Restaurant: _ Seating Capacity . _.._ _. ._Square Footage_ — _._. <br /> Food Handlers Course required:-YEs;[f- Na:❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> )]❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Mobile Food Vehicle-----Make Vehicle Type <br /> Registration# Color <br /> License# Sticker# <br /> ❑Mobile Food Prep Unit--Make Vehicle Type <br /> Registration# Color <br /> License# Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from <br /> to Cl Ice Plant <br /> ❑ Special Event --Dates of operation from to <br /> DAIRY PROGRAM (2000) ❑ Produce Stand <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUP A ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyelers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST _,1 <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> Hotel/Motel-------Number of Units ❑ Jail'or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Em fa ee Housin /Labor Cam A lication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water QualityRemediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard © Package Treatment Plant 11Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility' ❑ CIA Landfill Site <br /> ❑Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----112- 10-------❑ H --60------11>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVSElfiJ 46-02-003 Blue Application Form <br /> EMERGENCY NOYIFICATION FOR THIS FACILITY AND/OR PROGRAMA <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRA,NI ELEMENTZip FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# - PERMITVALID to ❑Food Handler <br /> ❑Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date t �' <br /> 48-02-034 <br /> 10/6d1003 Masterfile Record Pink <br /> - <br />