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- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing,Facility <br /> []New Eli Program and New Facility <br /> Facility ID 7 <br /> Pro ram Rccord ID <br /> Facility Address-'!q14 D fL' <br /> (Please Check the appropriate description and specify§1 e•number of units and Lertinent information) <br /> FOOD PROGRAM(1600) <br /> Footage Food Handlers Course required:. Yrs❑ No ❑ <br /> ❑Restaurant: Stating Capacity Square aration ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Drystorage only ❑ d Food❑P with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Retail Market—Square footage Color - <br /> ❑ Mobile Food Vehicle---Make Vehicle Type <br /> Registration# License# Sticker# <br /> Vehicle Type Color <br /> ❑ Mobile Food Prep Unit—Make License# Sticker# <br /> Registration# <br /> 13 Temporary Food Facility—Dates oto 11 lee plant <br /> [I <br /> operation from [I produce Stand <br /> [ISpecial Event —Dates of operation from to <br /> DAIRY PROGRAM(2000) <br /> 13❑ Grade A Dairy ❑Grade B Dairy MilkDispenser—Number of Containers in Multi-Head Unit <br /> -- CUPA ❑ State Facility Surcharge(2399) <br /> If?�ZARDROGRAM( <br /> OUS WASTE P2200) - 1 <br /> �I Hazardous Waste Generator. Tons Generated Per Year 7 -�� T��0 Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Conditionally Exempt 11 Appliance y Exe p <br /> Tiered Permitting Facility 11 Conditionally Authorized(CA) mpt(CE) <br /> t (2217) <br /> ❑ <br /> [I Pemut-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 /> ❑Hotel/Motel—NI,mber of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Emplar^^IfousiazUbor Camp Appfim6ou Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11 Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. [3NPLISEP Cleanup Site 11 UIC site <br /> ❑ Abandoned IIW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site .❑Water Quality Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool 13 Spa 11 Out of Service Pool/Spa ❑ Natural Balding Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO DODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ PumperVehide—Registration# <br /> License# Capacity Vehicle# <br /> ❑Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill L3 Transfer Station E3 Ag/Cannery Waste Site ❑Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑FarmfRauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4$00) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Ifauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---D 2-10—❑ l l-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use Pff'S FlIP 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON n Day Ph Night Ph <br /> PROGRAht ELFT%IIE�NT L22O FEE r� El Surcharge FEE 1:1 Other FEE <br /> INSPECrOR# '(�' 70 PERMIT VALID f to /.�l /� ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICES#J �} <br /> 0 Cash REVIEWEDnY - ! ACCOUNTING OFFICE Date p ,/ <br />