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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM w EH Program at Existing Facility ❑New EI1 Program and New Facility Facilit •ID Pro ram Record ID X01 Facility Address S• �' (Please Check the appropriate description and specify size,number of units and pertinent 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) I A.ZARDOUS WASTE PROGRAM(2200) ❑ hazardous Waste Generator. Tons Generated Per Year ❑Recycle I 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 NDERGROM%STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee housing(2700)Use Fmployee flousine/I,abor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑ NPLJSEP Cleanup Site ❑UIC Site ❑ Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑RNVQCB 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) ❑ Poultry Farm Maximum number of birds 11 Kenael TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) E] Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill 11 Transfer Station 11 Ag/Cannery Waste Site El 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 ❑Farm/Ranch 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—[] 2-10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS E11D 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CFI�� CONTACT PERSON Day Ph CZO'V - 320 Night Ph 2� -7383 PROGRAM ELE11tENT-::? FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# /Y,*� PERMIT VALID to ❑Food handler ❑ Check# M10 ID Date INVOICE# ❑ Cash REVIEWED BY J ACCOUNTING OFFICE Date ZZ IO