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SAN JOAQUIN COUNTY ENVIROW ENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM _ tNew EH Program at Existing Facility ❑New EH Program and New Facility Facilit •ID O O 0 O Program Record II) ( / Facility Address f K2, -00 - L (Please Check the appropriate description and specify ss_jji ,number of units and/Certinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ NO ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units ❑ Retail Market--Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration# License# Sticker# ❑ ]Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility----Dates of operation from to ❑ Ice Plant ❑ Special Event —Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) i ❑Hazardous Waste Generator-- Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST 2, 11(( UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms HOUSING PROGRAM(2400) ❑ Ilotel/hiotel Number of Units ❑Jail or Exempt Institution Number of Units Eotployee Housing(2700)Use Employee Ilousinz4zbor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) 11 Environmental Assessment [IUST-CAPSite 11 Local RV Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC site ❑ Abandoned IIW Site ❑ non-NPLJSEP Cleanup Site ❑R)VQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) 11 Poultry Farm Maximum number of birds ❑ Kennel TATTOO 11ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) El Tattooing(412 1) 11Body Piercing(4 120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑ Far ivRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--0 2- 10 ❑ 11-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff S END 46-02-003 Blue Application Form f� ERGENCY NOTIFICATION EOR TIM FACILITY ANDIOR PROGRAM CONTACT PERSON C' 13-04 r- Ph Night Ph PROGRAM ELEMErq-r �'Z/ FEE ❑ Surcharge FEF ❑ Other FEE INSPFCFOR# (�.'/ • PERMIT VALID to ❑ Food handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date e (q"