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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility New EH Program and <br /> /d New Facility <br /> Facility ID 0 0 2l� " Program Record ID QD 53T ! 0 0 <br /> Facility Address ��'l,u� S. ��b�f�5 QA. <4o( L cJ2b <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No ❑ <br /> ❑ CommissaryIJDry storage only 11with Food Preparation 11 Vending Machines—Number of Units <br /> ElRetail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vchicle--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—Datcs of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy 1:11 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 11Conditionally 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 HousinzlLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> El Environmental Assessment ❑UST-CAP Site 11 Local 11W Cleanup Site. ElNPL/SEP Cleanup Site 11 UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater 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/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 17 CIA 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 ❑ 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 PIYSEHD 46-01-003 BlueApplica6an Forret <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AN0/OR PROGRAM <br /> CONTACT PERSON i� Day Ph Night Ph <br /> PROGRAM ELEMENT LJ1u b FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMITVALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date / INVOICE# <br /> El Cash REVIEWED BY �� ACCOUNTING OFFICE N� Date 3 ,,S l C) <br /> D......�A D:-T, <br />