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SAN JOAQUIN COUNTY ENVIRONMENTAL I�EALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM RETE VE T <br /> ew EH Program and New Facility ,�U <br /> ❑New EH Program at Existing Facility L t <br /> Facilit,ID i : ° 4 Pro ram Record ID �i S✓� t 1 z_ SAN <br /> FN QAWR QUI O <br /> Facility Address NDpN°�Nl> <br /> (Please Check the appropriate description and specify size,number of units and Pertinent information) <br /> OOD PROGRAM(1600) <br /> estaurant Seating Capacity Square Footage Food handlers Course required:. Yrs No❑ <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 /> Color <br /> T <br /> Type❑ Mobile Food Vehicle---Make VehicleSticker# <br /> Registration# License# <br /> ❑Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> to ❑ lee Plant <br /> ❑ Temporary Food Facility—Dates of operation from 11 Produce Stand - <br /> ❑ Special Event -Dates of operation from to <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 /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑hazardous Waste Generator---Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221 s) ❑ 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(LIST)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 Fmnloree71ousin&TAbor Cama Anolimdon Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local IIW Cleanup Site. ❑NPLlSEP 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) ' <br /> ❑Poultry Farm—Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 13 Pumper Vehicle-Registration# License# Capacity Vehicle-# <br /> ❑ Pumper 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/Recyde 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---O 2-10—❑ 11-60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pll'S F.IID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR Tm5 FACILITY AND/OR PROGRAM <br /> CONTACT PERSON x- Day Ph - 0 Night Ph ll o <br /> PROGRANI ELEMENTf FEE�7, �y�15 y� 1, ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# ///X`Y' PERMIT VALID 1 '1 10 to 'I ❑Food handler 1, p <br /> PCheck# kD�—OeT� AMOUNT PAID OA Date �'�� LO (Z+ INVOICE# �5?T / <br /> EI Cash REVIEWED BY //� ACCOUNTING OFFICE Ddte —J <br /> M�er.�lr Rrrnrd Pinl- <br />