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p}-SAN JOAQUIN'�COUNTYf iRONMENTAL HEALTH DEPAF,,�NT ` MASTERFIL RECORD INFORMATION FORM ❑ New EH Pro ram at Ezis�ingFacilit ❑New EH Program and New Facilit Facilit ID 7 Pro ram Record ID D 341e S ) Facility Address l Z p L-r V) 7 (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM (1600) 13 Restau rant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No El 1Commissary El Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units 11 Retail Market—Square footage ❑ with Meat Market only [I Multiple Departments[] Prepackaged Goods Only I El Mobile Food Vehicle—Make Vehicle Type Color Registration# License# Sticker# 13 Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# 11 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 ❑ Milk Dispenser-Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ,r (2217) ❑ CRT Offsite Handlers(2218) ----------- ❑ Silver Only(2222) 11 Appliance Recyclers Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By- a Household Hazardous Waste VABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B form .r HOUSING PROGRAM(2400) 11Hotel/Motel----Number of Units ❑ Jail or Exempt Institution--- umber of Units Employee Housing(2700) Use Em to ee Housin /Labor Camp Application Form SITE MITIGATION(2900). UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLlSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTHIPROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ;� ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleReg stration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill .I ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility I ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#oflunits) ❑ Dumpsters>20 cu yd(#of Upas) ❑ 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 1:12- 10 1:111 -60 ❑ >60 generators PUBLIC WATER SYSTEM(PROGRAM (4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON �� Day Ph Night Ph PROGRAM ELEMENT D FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR `• / B PERMIT VALID to ❑ Food Handler ❑ Check# f AMOUNT PAID Date INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Date Ip !i r 4M2-034 MASTERFILE RECORD INFORMATION PINK