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I� eN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATIO ORM II ❑New Eli Program at Exkstin Facility AdNew Eli Program and New Facility Facility ID ragram Record ID Facility Address 50 v LT-9 u (Please Check the appropriate description and specify s_ue,number of units and pertinent information) II i FOOD PROGRAM(1604) I ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ 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 �I Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ii ❑ Ice Plant ❑ Special Event —Dates of operation from to © Produce Stand DAIRY PROGRAM(2000) it ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Numbcr of Containers in Multi Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200)' ( i ❑Hazardous Waste Generator. Tons Generated Per Year .❑Recycle 1 Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) _ ❑ Appliance Recyclers,(7217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit Permit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B s II �I HOUSING PROGRAM(2400) l ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Ifousing(2700)Use Employee Housift&L-ber Camp Application Form II SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) .II ❑ Environmental Assessment ❑UST-CAP Site ❑Local IW Cleanup Site• ❑NPLISEP Cleanup Site li ❑UIC Site ❑Abandoned IIW Site ❑non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site 13 Water Quality Remediation Site d RECREATIONAL HEALTH PROGRAM(3600) II Number of Pools/Spas at Facility. ❑Pool ❑Spa ❑Out of Service PooVSpa ❑Natural BatSing Area VECTOR CONTROL PROGRAM(4000) `I ❑ Poultry Farm Maximum number of birds ❑Kennel d TATTOO 13ODY PIERCING,PERMANENT COSMETIC-PROGRAM(4100) ©Tattooing(4121) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) O Pumper Vehicle--Registration# License# Capacity Vehicle# ❑Pumper Yard 13 Package Treatment Plant, ❑Chemical Toilets Numbtr of Units SOLID WASTE PROGRAM(440 0) ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Siudge/Ash 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/Rauch Cleanup Site II MEDICAL WASTE PROGRAM(4500) H • Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator 0 Small Generator ;i ❑Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ 11-40 >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS ERD 46-02-003 Blue Application Form �I EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM II CONTACT PERSON Day Ph Night Ph it PROGRAM ELEME _ FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID . to ❑Food Handler ❑ Check# AMOUNT PAID Date INVOICE#El li e Cash 1ZEYIEWED BY ACCOUNTING OFFICE Date I; II