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SAN JOAQUIN COUNTY E RONNIENTAL HEALTH DEPARTqWNT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Pro o m at Existing g Facili ❑New EH Program and New ity <br /> Facility ID F4 0 014 Biz Pro ram Record rD S <br /> Facility Address roro r>. `-t'1- / `-oo <br /> (Please Check the appropriate description and specify size.number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage - - Food Handlers Course required: -Yes 11 -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 /> ❑ Ice Plant <br /> El Temporary Food Facility-----Dates of operation from to <br /> 11 Special Event --Dates of operation from to 11 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 /> HAZA OUS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator------------Tons Generated Per Year 'c S ❑ 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 /> ❑ Pennit-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 LISTA and B forms <br /> HOUSING PROGRAM(2400) - - .. _ <br /> ElHotel/Motel-------Number of Units - ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camn AEalieation 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 ❑ RN1'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility 11 Pool ❑ Spa Cl Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm--Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑ Pumper Vehicle--Registration# License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> 11 Landfill 11 Transfer Station ❑Ag/Cannery Waste Site <br /> 1:1Process/Rec cle Facility ❑ CIA Landfill Site <br /> 11 Waste Tire Facility ❑ Compost Facility y <br /> ❑ Dum sters>20 cu yd--Number of Units ElFarnJRanch Cleanup Site <br /> ❑ Refuse Vehicles--Number of Units P <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10------❑ 1 l-60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIPS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> PROGRAM ELEMENT FEE .f,2fJt7 [] Surcharge FEE <br /> ❑ Other FEE <br /> INSPECTOR# J3L�2, PERMIT VALID t�yp� to (,Z/3l O L ❑ Food Handler <br /> 13Check# AMOUNT PAID �� ISI t.L- Date—= INVOICE# <br /> AceouNTINGOFFICE Date / 2p (� <br /> ❑ Cash REVIEWED BY ' <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/62003 <br />