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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD'INFORMATION FORM <br /> New EH Program at Exisiin Facility ❑i~1ew EH Program and Ne`v Facility <br /> Facilit ID Pro ram Record ID QpC race C�./G <br /> Facility Address Z J 1 <br /> (Please Check the appropriate description and specify sir number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers j. <br /> Course required:. Yss❑ No <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines--Number of Units <br /> ❑Retail Market----Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepa&agcd Goods Only <br /> ❑ Aiobile Food Vehicle--MakeVehicle Type Color <br /> Sticker# <br /> Registration# License# �— <br /> D Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility Dates of operation from to ❑ Ice Plant <br /> Q Special Event --Dates of operation from <br /> to 0-Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy 13 Grade B Dalry Milk Dispenser Number of Containers in Multi-Head Unit <br /> d CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200)' 1 <br /> ❑ hazardous Waste Generator. Tons Generated Per Year ❑Recycle 1 Exempt System(2299) <br /> Q CRT Offsite Handlers(2218) i7 Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility-------------D Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fined Unit ❑P it-By-Rule Household Hazardous Waste <br /> AgOYEGROUND STORAGETANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑HotdWotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> £ionployte Hansieg(2700)Use Employee Hausin /labor Cama Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJEMON CONTROL(3000) <br /> _[3Env�iroamental Assessment ❑UST-CAP Site 13 Local HW Cleanup site. E3NPLISEP Cleanup Site ❑UIC site <br /> ❑Abandoned HW Site Cl non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site '©Nater Qualify Remediation Site <br /> RECREATIONAL-HEALTH PROGRAM(3600) <br /> Number of PoolstSpas at Facility. 13 P901 El spa <br /> Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑Kenael <br /> TATTOO Bony PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vchicle# <br /> D Pumper Yard ❑Package Treatment Plaut ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> D Waste T'Ire Facility ❑ Compost Facility ❑ProcesslRecycle 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 D Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic D Common Storage Facility-----D 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Fonrn <br /> EMERGENCY NOTIFICATION roll THIS FACILITY ANDfOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PAOGI2AA1 ELEMEN-T *7, FEE ❑ Surcharge FEE'. [3 Other FEE <br /> INSPECTOR# ERIvIIT VALID . to ❑ Food Handler <br /> ❑ Check# AmouNT PAID Date _ IXVOICI=# <br /> 13 Cash REVIEWWBY ACCOUNTING OFFICE Date � 04 7 <br /> M­rrrflr krrnrri Pink <br />