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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New Ell Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit•ID f O v Program Record ID �J <br /> Facility Address // 6 141. <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) _ <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Pending 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# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to 13 Produce Stand <br /> DAIRY PROGRAM(2000) - - <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Ilead Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator. 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 /> yyy��� ❑Permit-By-Rule Fixed Unit ❑Perri y-Rule Household Hazardous Waste <br /> UD ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> / \\UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) _ - - <br /> ❑Hotel/Motel—Number of Units ❑Jail or Exempt Instil —Number of Units <br /> Employ"Housing(2700)Use F.mnlopee Irousinp/Le6or Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site_ ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(1600) <br /> Number of Pools/Spas at Facility ❑Puol ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTORCONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration.# License# Capacity Vehicle <br /> ❑Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets—Number of Units - <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site - <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Firm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care - ❑ Acute Care ❑ SkilledNursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10—1111-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PN'S BIrD 46-02-003 Blue Anpllcarion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT ZSR 4,40 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# f ®9 PERMIT VALID . to ❑ Food Handler <br /> ❑ CheckAMOUNT PAID Date INVOICE# <br /> [3 Cash REVIEWED BY ACCOUNTING OFFICE E' Date 1 <br />