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SAN JOAQUIN COUNT � _NVIRONMENTAL HEALTH DEPAm I'MENT <br />MASTERFILE RECORD INFORMATION FORM <br />ew <br />wuvcvv L11 , uy,dili di r-xlstmg race <br />Facilitv ID to fVy,) z/ -,Q I <br />❑New EH Program and New Facili <br />ram Record ID � �Z-D S13 S -L)'4 � <br />Facility Address Soo rif-flov, <br />Please check the p p p fY z 3 <br />( appropriate description and Spec size, num er of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle --Make <br />Registration # <br />❑ Mobile Food Prep Unit Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Vehicle Type <br />License # <br />License # <br />to <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments[] Prepackaged Goods Only <br />Color <br />Sticker # <br />R <br />Vehicle Type _ <br />Sticker # <br />Color <br />_ ❑ Ice Plant <br />❑ Produce Stand <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <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 Housinq/Labor 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Wate Q I' <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm -------Maximum number of birds <br />❑ Spa <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (# or units) <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care <br />❑ Transfer Station ❑ Veterinary Clinic <br />r ua ity Remediation Site <br />❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets ----Number of Units <br />E3Ag/Cannery Waste Site 11Sludge/Ash Site <br />E3Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Dumpsters > 20 cu yd (# or Units) 11Farm/Ranch Cleanup Site <br />El Skilled Nursing El Large Generator El Small Generator El Limited Hauler <br />❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />ROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br />ASPECTOR # ` PERMIT VALID t0 <br />ED Food Handler_ <br />❑ Check # AMOUNT PAID Date INVOICE # Date <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE i� Ll // -L) <br />ZL.._ <br />43-02-034 <br />11/15/07 AIASTERFILE RECORD INFORI'.IATION PINK <br />