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SAN:OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORDiNFORMATION FORM <br /> New EH Program at Existing Facility -[]New EH-Provm and New Facility <br /> Facilit •ID fd�l Program Record <br /> Facility Address f/ d A P G Y - _ .- . <br /> (Please heck the appropriate description and specify size. number of units and pertinent information_) <br /> FOOD PROGRAM 0600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines--Number of Units <br /> ❑Retail Market----Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# w <br /> ❑Mobile Food Prep Unit--Make Veliicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility----Dates of operation from - to 11 let Plant <br /> © Special Event --Dates of operation from to D Produce Stand <br /> DAIRY PROGRAM(2001)) <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑Mill:Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IiA7.ARDOUS WASTE PROGRAM(2200)" 1 <br /> ❑ Hazardous Waste Generatar. Tons Generated Per Year _ ❑Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permitt By Rule Fixed Unit a y-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B fo s l <br /> HOUSING PROGRAM(2400) <br /> 7 HotclWotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2790)Use EM toee Housin /Labor Cgrmp A lic_ ou Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) . <br /> 11 Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site 11 UIC Sife <br /> ❑ Abandoned HW Site ❑non-NPLISEP Cleanup Site ❑R\VQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard D Package Treatment Plant• ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ©Transfer Station ❑Ag/CanneryWaste Site ❑Sludge/Ask Site ' <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA•Landfitl Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing 13Large Generator Q Small Generator Q Limited Hauler <br /> 13Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----] 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD46-02-003 Blue AprgfcationForm <br /> EmEpcmNcY No rinc:ATIoN FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Alight Ph <br /> PROGRAM ELErtiwr FEE D Surcharge FEE '. ❑ Other FEE — <br /> INSPECTOR# Y VALID . to D Food Handler <br /> ❑ Check# AMOUNT PAID DateM INVOICE# p <br /> l] Cash REVIEWED BY AccouN T ING OFFICE Date q /&pfL <br />