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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New Ell Program at Existin Facility . [INewEllProgmandNewFacility <br /> Facilit•ll) ' Pro ram Record ID <br /> Facility Address C,2116 5 C�Q*-oU-e U4 W <br /> (Please Check the appropriate description and specify EjLe,number or 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 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 /> IIAOUS WASTE PROGRAM(2200) - 1 <br /> Hazardous Waste Generator. Tons Generated Per Year i S T 1:1 Recycle I 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 and B forms <br /> HOUSING PROGRAM(2400) - <br /> ❑AoteUMotel Number of Units I]Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)UseEmployee Ilousingjgbor Camp ApaUmdom Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site, L1NPLISEP Cleanup Site ❑UIC Site <br /> H <br /> ❑Abandoned W Site [Inon-NPLISEP Cleanup Site [3RWQCB 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 _ ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - <br /> ❑ PumperVehicle—Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ask Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIALandfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care 11Skilled Nursing 13Large Generator ❑ 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 PH'S E11D 66-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 2�L FEE �� � ❑Surcha e FEE ❑ Other FEE <br /> INSPECTOR# �� PERMIT VALID f C t0 �� B ❑Food Handier Q� <br /> ❑ Check# AMO�'!1,Na`T\PAID Date C INVOICE# 1? v <br /> F1 r..-�. Rcv,cwcn.nv /IIf�M 1 Accoi N ING OFFICF - Date o 9 21/y <br />