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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility <br /> OdNew EH Program and New Facility <br /> Facility ID o o�,0:2- � Pro ram Record ID <br /> Facility Address q 9, d A M A L2D SA ' 2_414 <br /> (Please Check the appropriate description and specify s¢ze number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ <br /> ❑ Commissary11Dry 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 /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# 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 /> 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 formes <br /> HOUSING PROGRAM(2400) <br /> ❑Ilotel/Motel Number of Un'" n * -- -�^^*r. f:i,.f:..n Number of Units <br /> Employee housing(2700)Use E plo Transfers•Farm Products•Bottom Dumps <br /> SITE MITIGATION(2900) Trucking Since 1964 (3000) <br /> ❑ Environmental Assessment SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned MY Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PRO FAIRCHILD FARMS, INC. /Spa ❑Natural Bathing Area <br /> Number ofPools/Spas at Facility_ 209-462-8195 g <br /> VECTOR CONTROL PROGRAM <br /> ❑ Poultry Farm Maximum 1 ❑Kennel <br /> TATTOO BODY PIERCING,PE 4900 E. Mariposa Rd.#A <br /> ❑ Tattooing(412 1) LOUIS BARBAGELATA Stockton, CA 95215 :1 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(42t,,,, <br /> ❑ 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 11Compost Facility 11Process/Recycle Facility 11CIA,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 1.1 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 PIVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT V: _'`d FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Q Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE _ Date (�O <br />