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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTf4ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> dNew EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID )Cio 4�90/ D,/ �Ls ` Program Record ID P-O S-j 8 t71,8 <br /> Facility Address �,_Prbc�41k4o- <br /> (Please Check the appropriate description and specify slLe 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 ❑Fending Machines—Number of Units <br /> ElRetail 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) a <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 /> ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Housinp/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-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 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 /> ❑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 I Cannery Waste Site ❑ Sludge/Ash Site <br /> AfWaste 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 ❑Acute Care ❑ Stdlled Nursing ❑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 Plf'S ElfD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 7��� FEE 11 Surcharge FEE ❑ Other FEE <br /> INSPECTOR# I'V1PERMITVALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY Q C>2./I" ACCOUNTING OFFICE Date �o (� <br />