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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPAR r ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro am at E��xistiD Facility <br /> ❑New EH Program and New Facili - <br /> FacilityID ftG Program Record ID - 02 <br /> Facility Address a�3 Irn r N t/iy <br /> (Please Check the appropriate description and specify size,number of units and pert! etit information.) <br /> FOOD PROGRAM(1600) <br /> [I Restaurant: Seating Capacity -..-.- -Square Footage <br /> - --- ----Food HandlersGourseregutred>—YEs❑. -NoO <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 /> Vehicle Type Color <br /> El Mobile Food Vehicle-----Make License# Sticker# <br /> Registration# - Color <br /> ❑Mobile Food Prep Unit--Make Vehicle Type <br /> Registration# License# Sticker# <br /> to 13Ice Plant <br /> ❑ Temporary Food Facility----Dates of operation from ❑ Produce Stand <br /> ❑ Special Event --Dates of operation from <br /> to <br /> DAIRY PROGRAM(2000) ❑ N \ <br /> ❑ Grade A Dairy ❑ Grade B Dairy Milk Dispenser--- umber of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> J�AZARDOUS WASTE PROGRAM(2200) stem p e/Exemcl <br /> 0 Recycle t S 2299 <br /> ❑ Hazardous Waste Generator-----------Tons Generated Per Year Y Y ( ) <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 /> '❑ HoteVMo[el-------Number of Units "❑ Jailor Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee HoasinelLabor Camp Application 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 ❑ RWQCB 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) ❑ 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# <br /> License# Capacity <br /> ❑ Pumper Yard - ❑ Package Treatment Plant ❑ ChemicalToilets- -Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Slud e/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site g <br /> ❑ Compost Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility P tY ❑ Process/Recycle Facility <br /> 11 Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ FarMRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) - - <br /> ❑ Primary Care 1:1Acute Care ❑ Skilled Nursing 11Large Generator ❑ Small Generator 11Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----02- 10------1111-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> ,CONTACT PERSON I <br /> PROGRAM ELEMFNTF-1='7cOD�UFEE / ❑ Surcharge FEErE ❑ Other FEEINSPECTOR# � VALID to I ❑Food Handler <br /> ❑ Check# AMOUNTPAID Date INVOICE -- <br /> N ACCOUNTING OFFICE Date <br /> ❑Cash REVIEW ED BY O <br /> - Masterfile Record Pink - - <br /> 48-02-034 <br /> 10/6/2003 <br />