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v <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existi¢ Facility ❑New EH Program and New Facitity <br /> Facilit •ID F A Q d 17q _Pia ram Record ID <br /> Fa effity Address 3 <br /> �T� Z A.r�r ( t,P �1 <br /> ao ro riate de-scri tion andspecify size,dumber of units and pertinent information.) <br /> (Please Check the ,P P P <br /> FOOD PROGRAM(160 0) <br /> F)Restaurant: Seating Capacity Square Footage Food Handlers Course required:- YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only Elwith Food Preparation ❑We¢diag Machines—Number of Units <br /> [IRetail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ElMobile 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 /> [ISpecial Event —Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM(20Q0) <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) a <br /> ❑Hazardous Waste Generator._— Tons Generated Per Year ❑Recycle I Exempt Systeme(2299) <br /> ❑ CRT Offsite Handlers (2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Perrait-lay-Rule Fixed Chit ❑Permit-lay-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B Torras <br /> HOUSING PROGRAM(2400) <br /> ❑ Iiotel/Diotel Number of Units -11 hail or Exempt Institution Number of Units <br /> Employeeliousing(2700)Use FmployeeHousirriTA bor Lamp Applica6an Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> El Environmental Assessment ❑ UST-CAP Site El Local MV Cleanup Site. ElNPIJSEP Cleanup Site 11 UIC Site <br /> ❑ Abandoned 1BY Site ❑ non-NPUSEP Cleanup Site ❑R)VQCB Cleanup Site ®iVater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3604) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing-Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farms Maximum number of birds 11 Kennel <br /> `TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooiag(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4204) <br /> 11 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 iWaste Site ❑ Sludge/Ash Site <br /> <:O Waste Tire Facility ❑ Compost Facility ❑ Process[Recycle Facility ❑ CIA-Landfill Site <br /> ❑ Refuse Vehicles—Number of Units _ ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator Cl Small Generator El Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PJVSEfTDf6-02-003 BlueApplica6ori Form <br /> EMERGENCY('NOTIFICATION FORTHis FACILITY AN© OR PROGRAM <br /> CONTACT PERSON_ Day Ph Night Ph — <br /> PRocm-otELENIEtiT_kAn1� 0 FEE—_ ❑ Surcharge FEE ❑ Other FEE <br /> 1NsrEcToR# --(oZL PERMITVALID to ❑ I+oodHandler_._ <br /> 11 A_nT0UN1-RUD DateIt1VOICE 11 _-- _--- <br /> _._.. <br /> t Q(� v <br /> Cash t�VIF-VIED BY V v `1�11 j 11 ACCOUNTING OFFICE Date r l b <br />