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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT io S MASTERFILE RECORD-INFORMATION FORM ❑New EH Pro at Existing Facility ew EH Pro and New Facility U�C � Facilit•ID C) Pro ram Record ID Facility Address v �El?�j/ F ��F LTH (Please Check the appropriate description and specify six number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food handlers Course required:. YEsA No❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending Machines Number of Units ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only ❑Mobile Food Vehicle----Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility---Dates of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) 9 ❑hazardous Waste Generator. Tons Generated Per Year [3 Recycle!Exempt System(2299) [3 CRT Offsite Handlers(22 18) E3Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Per tuitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Nurnber of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and.9 forms HOUSING PROGRAM(2400) ❑ HoteUMotel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housiag(2700)Use Empleree Ifo uslnp/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 13 Environmental Assessment ❑UST-CAP Site 11 Local RW Cleanup Site. 13NPLISEP Cleanup Site 13 UIC Site ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. 13 Pool [3 spa ❑Out of Service PooVSpa ❑Natural Bathing'Area VECTOR.CONTROL PROGRAM(4000) ❑Poultry Facet Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) [3 Tattooing(4121) 11 Body Piercing(4120) 11 Permanent Cosmetic(4122) LIQUID WASTE PROGRAM(4200) 13 Pumper Vehicle—Registration# License# Capacity Vehicle.# ❑Pumper Yard ❑Package Treatment Plant- ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) [3 Landfill 11 Transfer Station 13 Ag I Cannery Waste Site [3 Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑CIALandfill Site ❑Refuse Vehicles Number of Units ❑Dumpsiers>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care . ❑Acute Care ❑ Skilled Nursing ❑Large Generator 0 Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11-60---❑>60 generators PUBLIC WATER SYSTEM_ PROGRAM(4600)Use TIIBEMD 46-02-003 Blue Application Form _ EMERGENCY NO IFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON / 1 e `� S �� Day Ph -�r 2 i Night Ph PROGRAM ELEMENT «3 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 3`f7-1 PERMIT VALID \Ato �P 136 ❑Food Handler ❑ CheckMIOUNT/PAID G*P-( Date —�— INVOICE# 0 Cash REVIEWED BY r -3 I ACCOUNTING OFFICE Date 1-Z U b