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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />MASTERFILE RECORD INFORMATION FORrVI (EH 00 <br />X New EH Program at Existing Facility ❑New EH Pruram and-New.Facility <br />11 Facility ID W%1?,V11 -5T, 7 bn 15 Program Record ID ' '�)I h 110 VD I <br />Ca.li� -e�f- <br />o� --mvtsp. <br />Facility Address �� /_.► �f �� ?�2�C�; ..�o c.- 1%if� <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) p�b oa 37 8 <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square 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 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 />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator -----------------------Tons Generated Per Year <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 i & ®�Ja��Q <br />UN ERGROUND 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 />Employee Housing (2700) Use Employee Housint tlLabor Camp application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ 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 <br />❑ Kennel <br />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration # License # Capacity <br />Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets -------Number <br />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 ❑ Dumpsters > 20 cu yd ---Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----❑ '_ - 10 <br />------- ❑ 11 - 60 ------❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EI -10069 Blue Application Form <br />FmPmr.Fucv NnTIFirATInN FOR THis FACILITY ANO/OR PROGRAM <br />CONTACT PERSON <br />PROGRAM ELEMENT <br />INSPECTOR # <br />❑ Check # _ <br />❑ Cash <br />FEE _ <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY <br />EH 0069 PINK FORM.doc <br />Day Ph (� I <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />.6 Night Ph <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE #� <br />Date <br />Rev. 07/07/99 <br />