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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 11 New EH Pro at ExistingFacility *ew EH Pro and New Facility <br /> Facilit X ID Program Record ID 6 <br /> Facility Address mL�N CA2SIOS <br /> (Please Check the appropriate description and specif s' number of units and pertineut information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant Seating Capacity Square Footage Food Handlers Course required:. Yrs❑ No ❑ <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Mathies—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 It 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 /> IIA RDOUS WASTE PROGRAM(2200) i <br /> JR Hazardous Waste Generator.- Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(22 18) ❑ Silver Only(2222) ❑Appliance Recyclers(22.17) <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) Numberof AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ noteVMotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employ"Housing(2700)Use Einde eHousinglLaborCampAnoficarionForm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTRO43000) <br /> -❑Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPL/SEP 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 Pools/Spas at Facility ❑r9ol ❑ Spa ❑Out of service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) _ <br /> ❑Poultry Farm—Maximum number of birds 13 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) 11 Body Piercing(4120) 11 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# - License# CapacityVehicle# <br /> ❑ Pumper Yard Or age Treatment Plant ❑ Chemical Toilets—Numbaof Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑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 ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) _ <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator 0 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2- 16-1111-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIIS EFID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcbarge FEE ' ❑ Other FEE <br /> INSPECTOR# 1� PERMIT VALID . to ❑Food Handler- <br /> Check# <br /> andlerCheck# AMOUNT PAID Date INVOICE#� <br /> ❑ Cash REVIEWERBY h(, `l-`f-r ACCOUNTING OFFICE Date <br />