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SAKI JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility ❑New EH Program and New Facility Facilit L ZD /V Pro ram Record ID Facility Address _. .`).� p ZV-_ 7_ .G 1eA1?0111 (Please heck the appropriate description and specify sin___e. number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restauraut: _Seating CapacitySquare Footage Food Handlers 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# ❑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 S Dalry ❑Milk Dispenser---Number of Container's in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) IiA.7.ARDOUS WASTE PROGRAM(2200) y ❑hazardous Waste Generator. Tons Generated Per Year 1❑Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit .❑Pe y--Rule Household Hazardous Waste 1�#ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST fZ .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST:t and B forms HOUSING PROGRAM(2400) ❑Hotd/Mote1 Number of Units ❑Jail or Exempt Institution Number of Units krnployee Housing(2700)Use Fjnployee Housrn l ubor CompApprimdon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment UST-CAP Site ❑Local HW Cleanup Site. ❑NPIISEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site, ❑RWQCB Cleanup Site ❑VYater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Poo1/Spa ❑Natural Bathiag Area VECTOR CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO,BODY PIERCING.PERMAN5UT COSMETIC PROGRAM(4100) ❑Tattooing(4121) ❑Body Piercing(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) ❑ Landfdl ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA;Landfill Site ❑Refuse Vehicles--Number of Units ❑ Dumpsfers>20 cu yd Number of Units ❑ 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--0 2-10 ❑ 11-60----❑ >60 generators PUBLIC WATER_ SYSTEM PROGRAM(4600)Use PHIS EHD 46-02-003 Blue Application Form EMERGENCY N0T1FtCATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT Z S 7 FEE ❑Surcharge FEE"'. ❑ Other FEE IrtSPEGTpR# -B 1j1kjPPERMITVALID to ❑ Food Handler ❑ Chcck It AMOUNT PAID Date INVOICE# ❑ Cash R6viFwFUBY Accou YTwG OFFICE Date s Q