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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ID '�-]`�ti Pro ram Record ID <br /> Facility Address 4 r� ti CA <br /> (Please Check the appropriate description and specify s¢dnumber 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 [ Fending 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 /> CU PA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) [1Silver 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 /> BOVEGROUND 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 Exempt Institution Number of Units <br /> Employ"Housing(2700)Use Fmployee IfousinKabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site, I ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned MY Site ❑non-NPLISEP Cleanup Site ❑RwQCB Cleanup Site 13 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 13 Pool 11 spa ❑Out of Service Pool/Spa 11 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 11 Ag/Cannery Waste Site 11Sludge/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 ❑Farrn/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Sldlled Nursing ❑Large Generator 0 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 Pff S EHD 46-02-003 fibre Application Form <br /> EME NCY NOTIFICATION FOR THIS FACILITY ANDIOF2 PROGRAM <br /> CONTACT PERSON e 11lt�CY�N Day Ph ^ Q NightPh <br /> PROGRAM ELEMENT FEE 11 ❑ Surchar etFEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID t to �O� 1 �� ❑ Food Handler <br /> ❑ Check# As OUNT PAID Date INVOICE# l <br /> 13 Cash RfiVIEWED BY E �'�-' � ACCOUNTING OFFICE Date <br />