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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />MASTERFILE RECORD Pt 1FORttiL4TION FORINI (EH 00 <br />VNew EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID r-IIn Z 1 n <br />Program Record ID f �-G 3 <br />Facility Addresses �►% r!� A�T6rl1d--- 0140 <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) -11 <br />❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes ❑ No ❑ <br />❑ Commissary ❑ Dry 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 <br />Registration <br />❑ Mobile Food Prep Unit—Make <br />Registration T <br />❑ Temporary Food Facility --Dates of operation <br />❑ Special Event - Dates of operation from <br />Vehicle Type <br />License <br />Vehicle Type <br />License R <br />from to <br />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 -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZA OUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator ----------------Tons Generated Per Year C <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 />❑ HotellMotel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee HoushrzlLahor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local H:V 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 Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Lfatural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration >r _ <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />Capacity . <br />C3 Chemical Toilets <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Vehicle ar <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill C1 Transfer Station C1 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 C1 Small Generator C1 Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 BlueAyelieation Form <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day Ph <br />Night Ph <br />PROGR INI ELEh1ENT 2-a,o FEE Y('300 ❑ Surcharge FEE ❑ Other FEE <br />I, ISPECTOR # PERmrr VALID !� l (0 3 to l' -I s i (a3 ❑ Food Handler_- <br />❑ Cheek a A�HOcrvT PAID ILL Date INVOICE # • l oS-�l S 1 <br />❑ Cash REVIEWED BY <br />EH 0069 PfNK FORM.doc <br />ACCOUN ING OFFkE <br />2 Date 3 /37 ( O <br />ftev. 07/07/99 <br />