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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART112ENT MASTERFILE RECORD INFORMATION FORM ❑New EH Pro am at Existing Facility ❑New Ell Program and New Facility FaciIit•ED &/_P/qL37Z Program Record ID l �/✓� r Facility Address � � (Please_Check the appropriate description and specify size,number of units and pertinent information. FOOL] PROGRAM(1600) 11 Restaurant: Stating Capacity Square Footage Food Handlers j. Course required.. Yrs❑ No❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market----Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# . 13 Temporary Food Facility-----Dates of operation from to ❑ Ice Plant E3 Special,Event --Dates of operation from to ❑ Produce St Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser---NumNw of Containers in Multi Head Unit Y CUPA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑Hazardous Waste Generator. Tons Generated Per Year 1❑Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Reayclers(2217) Tiered Perming Facility. ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit By Rule,Fined Unit Permit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST/Y / UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and -f s HOUSING PROGRAM(2400) ❑HoteUMotel Number of Units ❑Jailor Exempt Institution Number of Units Employee Housing(2700)Use Em to eeHousin /Labor Camg AppIkgdon Fonn SITE MITIGATION(2900) UNDERGROUND INJECTION CONTR91(30W) 0 Environmental Assessment [3UST-CAPSite ❑Local HW Cleanup Site, ❑NPLISEP Cleanup Site 13 UIC Site ❑Abandoned MY Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number ofPools/Spas at Facility. ❑P901 © Spa ❑Out of Service PooVSpa [I Natural Bathing Area VECTOR.CONTROL P ROG"M(4000) ❑Poultry Farm Maximum number of birds 13 Kennel TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) 11 Body Piercing(4120) [1 Permanent Cosmetics(4122} LIQUID WASTE:PROGRAM(4200) [3 pumper Vehicle—Registration# License# Capacity Vehicle# ❑Pumper Yard ❑Package Treatment Plant, ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑ Transfer Station 13 Ag t Cannery Waste Site ❑ SladgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles--Number of Units ❑Dumpsters>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) [3Primary Care ❑Acute Care ❑ Skilled Nursing 13Large Generator 0 Small Generator 13 Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-43 2-10 ❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWSFHD 46-02-003 Blue Application Form EMERGENCY NOW-ICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to ❑Food Handier ❑ Check# AMOUNT PAID Date INVOICE# El Cash IZEviBwE6 BY ACCOUNTENG OFFICE Date x.,.erP�FP Arrnrrl Pin!