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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ❑New Ell Program --an New Facility <br />Facility ID rQ Program Record ID hCD C <br />Facility Address 12 loll L AVT <br />(Please Check the appropriate description and specify EiLe, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food handlers Course required: YEs ❑ No 11 <br />❑ Commissary11Dry 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 <br />Registration # License # <br />❑ Mobile Food Prep Unit—Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility—Dates of operation from to <br />❑ Special Event —Dates of operation from to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -/lead Unit <br />COPA ❑ State Facility Surcharge (2399) <br />I►AZARDOUS WASTE PROGRAM (2200) i <br />❑ hazardous Waste Generator. Tons Generated Per Year ❑ Recycle I Ezempt System (2299) <br />❑ CRT Offsite Handlers (221 s) ❑ 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 UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel Number of Units ❑ Jail or Ezempt Institution Number of Units <br />Employee housing (2700) Use Fmplevee Ilousin--/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local IIW Cleanup Site, ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned IIW Site ❑ non-NPLJSEP 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 (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity <br />Vehicle# <br />❑ Pumper Yard ❑ Package Treatment Plant. ❑ Chemical Toilets <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsiers > 20 cu yd —Number of Units <br />❑ Farm/Ranch 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 --O 2 -10 <br />❑ 11- 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIES EffD 46-02-003 Blue Application_ Form <br />EMERGENCY NOTIFICATION FOR This FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph <br />Night Ph <br />PROGRANt ELEMENT S4_ FEE ❑ Surcharge FEE <br />❑ Other FEE <br />INSPECTORI`L- " 7 / l PER IIT VALID to <br />❑ Food /Handler <br />❑ Check # AMOUNT PAID Date <br />INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE <br />Date 1 <br />