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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFIL,E RECORD INFORMATION FORM <br />Facility Address -I JvP/l Ll ; �:C V? <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />�2k< <br />❑ Restaurant: <br />Seating Capacity <br />Square Footage <br />Food Handlers Course required:_. Yrs ❑ No ❑ <br />❑ Commissary <br />❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines —Number of Units <br />❑ Retail Market <br />—Square footage <br />❑ with Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle ---Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit—Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility—Dates of operation from to <br />❑ Special Event —Dates of operation from to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ 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 />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator. Tons Generated Per Year ❑ 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 />❑ 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 />❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Ilousine/J_abor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local BW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned IiW Site ❑ non-NPWSEP 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) <br />❑ Poultry Farm Maximum number of birds ❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity Vehicle# <br />11Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of 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 ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --0 2 -10 ❑ 11- 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIPS EffD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> 11 <br />PROGRAM ELEMENT �/ FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # �!� t ;� PERMIT VALID . 'i % to�,5 ❑ Food Handler <br />❑ Check # UNT PAID Date INVOICE # <br />❑ Cash REVIEWED ACCOUNTING OFFICE Date G <br />P—M Pint- <br />