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SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPAd NT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility []New EH Program and New Facilit Facility ID / 3 Z Program Record ID / 3 Facility Address S- /Vigo 15--Tc- Ow (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ 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 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 B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator----------- Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility------------------- ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) (yam ❑ Permit-By-Rule Fixed Unit ❑ Permit-By- Household Hazardous Waste U1q ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use UST A and 8 forms x HOUSING PROGRAM(2400) CJ 11Hotel/Motel------Number of Units ❑ Jail or Exempt Institution umber of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ElPumper Yard ElPackage Treatment Plant ElChemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd(#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 112- 10 ❑ 11 -60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITYAND/OR PROGRAM CONTACT PERSON i� Day Ph Night Ph PROGRAM ELEMENT tJ FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR#/,Plj Q PERMIT VALID t0 ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date per[ 48-02-034MASTERFILE RECORD INFORMATION PINK 11//15/0715/07