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SAN JOAQ <br /> UIN COUNTY ENVIRONMENTAL HEALTH DEPARTAIL,INT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit •ID 2:0 D a P1 �-3 Program Record ID ISO 3�Ylc 3 <br /> Facility Address �J�I nr�x � YO►'71•� `�> O <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(160 0) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs 11 No El <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending 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-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) y <br /> ❑ Hazardous Waste Generator-=— Tons Generated Per Year ❑ Recycle I 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 /> ❑ HoteUMotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee tfousinzagbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local IIW Cleanup Site• ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP 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 PoollSpa ❑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(4 121) ❑Body Piercing(4 120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <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 El Transfer Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ,;KNVaste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA-Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care ❑ Acute Care 11Skilled Nursing 13 Large Generator Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIPS EITD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph — <br /> PROGRAh1 ELEMENT-9790— FEE ❑ Surcharge FEE — ❑ Other FEE <br /> INSPECTOR# — PERMIT VALID _ to ❑ Food Handler —_ <br /> Check _ AmOUNT'PAID ---_--- Date _ INVOIcI #— ----!-�------_-'--- <br /> ❑ Cash RFviF+`!Fb ay AccouNTING.OFFICE hate v <br />