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NOW <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Prog aam at Existing Facility IdNew EHnPropt and New Facility <br /> Facilit•ID T A®® `�\ ` Pro ram Record ID IC.O 7I,I�S <br /> Facility Address 2�>Z VVA SI 6t, g- Ovl S-` STrt— <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 [IN,endiu-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 ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> 4�CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)` l' <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 /> ❑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 USTA and R forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housin—g/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site b Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ 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 ❑ 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 ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2- ENVIRONMENTAL HEALTH <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form DEPARTMENT NO LONGER <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR INSPECTS WASTE TIRE <br /> CONTACT PERSON Day Ph FACILITIES. It is a State run <br /> program effective 7/1/2017. <br /> pL <br /> PROGRAM ELEMENT `f-�q O FEE ❑ Surcharge FEE <br /> INSPECTOR# / f (® PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID DateINVOICE# <br /> 11 Cash REVIEWED BY 5 ®d ACCOUNTING OFFICE a Date S_ <br /> P—M Pinl- <br />