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- <br /> SAN JOAQUIN COUNTY F�NVIRONMENTAL HEALTH DEPARTMENT <br /> MA STERFILE RECORD-INFORMATION FORM <br /> 1 New EH program at Ex' tin Facility <br /> ❑NeW EH Program and New Facility <br /> Facilit ID v Pro ram Record ID <br /> Facility Address S'O ArA <br /> . �i2ra c� <br /> {Please Check the appropriate description and specify sistze'number of units and eminent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage <br /> ❑ Commissary []D Stora a only g Food Handlers Course re aired;. yr <br /> s❑ No C1 <br /> Dry g Y ❑with Food Preparation ❑'ending Ma a: —Number of Units <br /> ❑Retail Market=--Square footage with Meat Market only ©Multiple is <br /> 11 Mobile Food Vehicle-----Make DePattmen IJ Prepackaged(',Dods Only <br /> Registration# Vehicle Type Color - <br /> ❑Mobile Food Prep Unit—Make License# Sticker# <br /> Registration# Vehicle Type Color <br /> ❑Temporary Food Facili pe License# Sticker# <br /> ty-�----Dates of Operation from <br /> Q Special Event --Dates of operation from to to 13 Ice Plant <br /> DAIRY PROGRAM(2000) ❑ Produce Stand <br /> ❑ Grade A Dairy Cl Grade B Dairy 0 Mille Dispenser—Number of Containers in Multi-Head Unite <br /> �_• CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS.WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Genera tor---»_ Tons Generated Per Year <br /> ❑CRT Offsite Handims(2219) ❑Silver Only(2222 ©Recycle liExempt System(2299) <br /> Tiered Per-nutting Facile _ ) n 17 Appliance Recyclers(2217) <br /> tY ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Pen-nit-BY-Rule Fixed Unit ❑ By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA an;B oro ` <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motd Number of Units ❑Jail or Exempt Institution Number of units <br /> Employee Housing(2-100)Use Emple ei ffousine/Labor Camp Appliarlrou Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> -❑ Environmeatal Assessment ❑UST-CAP Site ❑Local I1W Cleanup Site. ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPIJSEP Cleanup Site 0 R)VQCB Cleanup Site E3 Water Quality Remediation Site ' <br /> RECREATIONAL HEALTH PROGRAM(3600) { <br /> Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out of Service Poe!/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(4 120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle-Registration# License# Capacity Vehicle.# <br /> ❑Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station 13 Ag I Cannery Waste Site ❑ SiudgelAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIALandfill Site <br /> ❑Refuse Vehicles Number of Units ❑Durr&ers>20 cu yd Number of Units ❑ FarmtRanch CleanuP Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> © Primary Can ❑Acute Care ❑ Skilled�Nursing ❑Large Generator Q Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility----13 2-H) ❑ t 1-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EIfD 46-02-003 Blue Aeplication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACTPEUSON m Day Ph Night Ph <br /> PROGRAM ELENIEN'T 2 b b FEE ❑ Surcharge FFE '- ❑ Other FEE <br /> INSPECTOR# I�tAL.ID . to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICI # <br /> El Cash REVIEWED BY ACCOUNTING OFFICE <br /> &A,11.61r 8-111 Pink <br />