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SAN JOAQUIN COUNTY ErWMRONMENTAL HEALTH DEPAR"1., -NT <br /> MASTERFILE RECORD INIFORMATION FORT <br /> 0 ram and New Facility <br /> New EH Program at Existing Facility <br /> Program Record ID <br /> Facility ID o I C),l [(O 'A <br /> Facility Address DOD � v T u � <br /> (Please Check the appropriate description and specify size,nmbeits and pertinent information.) <br /> FOOD PROGRAM(1600) g uare Footage Food Handlers Course required: - YEs❑ No ❑ - <br /> ❑Restaurant: Seating Capacity q❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only <br /> ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Retail Market----Square footage Vehicle Type Color <br /> ❑ Mobile Food Vehicle-----Make License f Sticker# <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit--Make License f Sticker# <br /> Registration# to _0 Ice Plant <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Produce Stand <br /> ❑ Special Event --Dates of operation from <br /> DAIRY PROGRAM(2000) ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year ❑ Recycle/Exempt System(2,299) <br /> ❑ Hazardous Waste Generator------------ Mance Recyclers (2217) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(222th ❑ Conditionally Exempt(CE) <br /> Tiered PermittingFacility------------- ❑ Conditionally Authorized(CA) <br /> y— ❑ Permit-By-Rule Fixed Unit ❑�Zp_emut-By-Rule Household Hazardous Waste <br /> ( BOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST- - — <br /> U`1DERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) ❑ Jail or Exempt Institution Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee Housing(2700)Use Emplolee Elousin Camp <br /> lLabor Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ite UIC Site <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ S°te 1 HN�CR„QCB Cleanup p Site PL/SO`Water Quleanup S <br /> ality Reme❑diiation Site <br /> ❑ Abandoned HW Site ❑ non NPL/SEP Cleanup <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ put of Service PooUSpa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm----Maximum number of birds <br /> TATTOO BODY PIERCINGS PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity_____ Vehicle# <br /> License# <br /> ❑ Pumper Vehicle--Registration# ❑ Package Treatment Plant ❑ Chemical Toilets-----Number df Unfits <br /> ❑ Pumper Yard <br /> ROGRAM(4400) ❑ Sludge/Ash Site <br /> SOLID WASTE P <br /> ❑ Transfer Station ❑ Ag/Cannery Waste Site [I CIA Landfill Site <br /> C1 Landfill ❑ Process/Recycle Facility <br /> El Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> 11 Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> ❑ Primary Care ❑ Acute Care <br /> ❑ Skilled Nursing ❑ Large Generator _❑ 11 -60-----❑ >60 generators <br /> ty __- <br /> ❑ Transfer Station [I Veterinary Clinic <br /> ❑ Common Storage Facility ❑ 2-10----- <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS END 46 02- ation Form <br /> Blue Applic <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAMNight h <br /> Day Ph <br /> CONTACT PERSON ❑ Other FEE <br /> FEE _ [3 Surcharge FEE� <br /> PROGRAM ELEEMENT 3� t° ❑ Food Handler <br /> INSPECTOR# O PERMIT VALID INVOICE# <br /> AjmOUNT PAID Date i <br /> ❑ Check# Date <br /> ACCOUNTING OFFICE <br /> ❑ Cash Masterfile Record Pmk <br /> REVIEWED BY <br /> 4"2-034 <br />