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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> VI <br /> New EH Program atExistin Facility <br /> ❑New l;H Program and Ne-,v Facility <br /> Facilit•ID a�jf 4� Pro ram Record ID <br /> Facility Address <br /> 2_ !700GA(V a� c <br /> i. <br /> (Please Check the appropriate description and specify siz number of units and pertinent information.} <br /> FOOD PROGRAM(1500) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required YES❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation Elven,ding 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 /> [3 Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# Lioense# Sticker# <br /> ❑Temporary Food Facility-----Dates o_f operation from to ❑ Ice Rant <br /> ❑ Special Event --Dates of operation from to 11 Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> t CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle 1 Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) CI Silver Only(2222) ❑ Appliance RecyclerS(2217) <br /> Tiered Permitting Facility---❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE'TANK(UST)PROGRAM(2300)Use LISTA and B arm 3 <br /> HOUSING PROGRAM(2400) <br /> U3 Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee ifousing(2700)Use F,mpleyeAausinr/Labor Camp APP Ca it Form <br /> SITE MITIGATION(2900) -- UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local llW Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site '13 Water Quality Remediation Site.' <br /> RECREATIONAL NEALT'H PROGRAM(3500) <br /> Number of PoolslSpas at Facility. ❑PQoI ❑ Spa ❑Out of Service PoollSpa E3 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farms Maximum number of birds [I 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 /> ❑ Pamper Yard ❑Package Treatment Plant- ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag I Cannery Waste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Proms/Recycle Facility ❑CIALandfilI Site <br /> ❑Refuse Vehicles Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ' ❑Acute Care ❑ Skilled'Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EI1D 46-02-003 Blue A licalian Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAI►f ELEMENT O FEE ❑ Surcharge FEE'-. ❑ Other FEE <br /> INSPECTOR# /3 1 1 PERMIT VALID . to D Food IIandler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> 0 Cash RmEwED DY ACCOUNTING OFFICE Date <br />