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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 1:1New Ell Program at ExistingFacility New EH Pro and New Facility <br /> Facilit•ID .:'D /g a Program Record ID 'J <br /> Facility Address /2 q tS / ' 6�'� <br /> (Please Check the appropriate description and specify s,izg number 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 ❑Vending Machiues—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 /> CUPA ❑ State Facility Surcharge(2399) <br /> ILUARDOUS WASTE PROGRAM(2200)" i <br /> ❑ hazardous Waste Generator Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver 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 /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A andft forms <br /> HOUSING PROGRAM(2400) _ - <br /> ❑Ilotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee IIousing(2700)Use F.mploree flousior&4or Camp Apr Umdon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPIISEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pcols/Spas at Facility ❑ Pool ❑Spa ❑Out of Service PoolfSpa ❑ 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 —ff Package Treatment Plant ❑ Chemical Toilets—Number of Units - <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑Ag f Cannery Waste Site ❑ SludgefAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcessfRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ FarmfRtnch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care - ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Ilauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—❑ 2- 10—El 11-60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS611D 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDfOR PROGRAM <br /> CONTACT PERSONaa Day Ph Night Ph <br /> PROGRAM ELEMENT 1.Q-a'0 FEE ❑Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMrr VALID . to ❑ Food handler <br /> ❑ Check# AMOUNT P�AII�D"(> 0Date INVOICE# <br /> ❑ cash REVIEWEDBY ! +y veI ACCOUNTING OFFICE Date <br />