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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTII1NT MASTERFILE RECORDNFORMATION FORM ❑New EH Pro ram at Existing Facility New EH Program and New Facility Facitit•ID Program Record ID Q57 .i Facility Address d (Please Check the appropriate description and specify gm number of units and Pertinent information) FOOD PROGRAM(1604) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ No ❑ ❑ Commissary ❑Dry storage only ❑ with Food Preparation ❑Tending Machines Number of Units ElRetail 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 Veliicle.Type Color Registration# License# Sticker# ,i ❑Temporary Food Facility—Dates of operation from to ❑ Ice Plant ❑Special Event --Dates of operation from to ❑Produce Stand 4 DAIRY PROGRAM(2440) ❑Grade A Dairy ❑ Grade S Dairy ❑Milk Dispenser---Number of Containers is Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) 1 ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Ezeznpt S)item(2299) • CRT Offsite Handlers(2218) f] Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility---..'. ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed P1nit Pcrmit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST).(2390) Number of / _ UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) [I Ilotel/Motel Number of Units 11 Jail or Exempt Institution Number of Units Employee Rousing(2700)Use Emaloyee Housing/Labor eampApplicaderr Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTRO43000) .❑ Environmental Assessment ❑UST-CAP Site 111,ocai BW Cleanup Site. [3NPLISEP Cleanup Site:: ❑UIC Site L3a N Abandoned I1W Site ❑noPLJSEP Cleanup Site ❑RNVQCB Cleanup Site '❑Nater Quality-Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas at Facility ❑Pool ❑Spa 0 Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) [3Poultry Farm Maximum number of birds ©Kennel TATTOO, _ 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) 13 Body Pierdug(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) , ❑Pumper Vehicle--Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑Package Treatment Plant, ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag 1 CanneryWaste Site ❑ S16dgelAs4 Site ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA,,LandfilI Site ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu:yd—Number of Units ❑Farm/Rauch Cleanup Site MEDICAL,WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator Small Generator ❑ Limited hauler 13 Transfer Station ©Veterinary Clinic ;' ❑ Common Storage Facility---0 2-14 0 11-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue AMticadanForm ' EMERGENCY NOTIFICATION FOR THIS FACILITY ANOIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM I L,EmENT FEE ❑ Surcharge FEE '. ❑ Other FEE INSPECTOR# PERMIT VALID to © Food Handler 11Check# AMOUNT PAID Date INVOICE# ❑ Cash REViEWED-BY ACCOUNTING OFFICE Date Pen!- .