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Ak .SAN'JOAQUIN COUNTY EN`x ONMENTAL HEALTH DEPART T MASTERFILE RECORD INFORMATION FORM ❑New EH Proeram at Existing Facility r'5ew EH Pro ram and New Facility Facility ID (�u 1-7(D( Program Record ID Facility Address 1(09 .'� 2;rle (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No El ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit -`-take Vehicle Type Color Registration# License# Sticker# 11 Temporary Food Facility-----Dates of operation from to 11 Ice Plant El Special Event --Dates of operation from to 1:1 Produce Stand DAIRY PROGRAM (2000) El Grade A Dairy El Grade B Dairy C3 Milk Dispenser --Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility------------------F-1 Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Wast,- 1:1 ast:❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number ot'AST UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/.Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units EmploNee(lousing(2700) Use Employee Flousina/Lahor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) C3 Environmental Assessment ElUST-CAPSite ❑ Local HW Cleanup Site 1:1NPL/SEP Cleanup Site El UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facilit% F-1Pool El Spa El Out of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM(4000) 1:1 Poultry Farm -------:Maximum number of birds 11 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) LIQUID WASTE PROGRAM(4200) El Pumper Vehicle -Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM(4400) } ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Process/Recycle cle Facilit El CIA Landfill Site ;1�,W:rstc"I'irc Facility ❑ Compost Facility )� y El Uum stern>20 cu d----Number of Units ElFarm/Ranch Cleanup Site El Refuse Vehicles--Number of Units ____ P• y MEDICAL WASTE PROGRAM(4500) El Primary Care El Acute Care El Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler 11 Transfer Station El Veterinary Clinic El Common Storage Facilih -- ❑ 2 10---- - 1:1 1 I -60-- - 1-1 >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use P{VS EHD 46-02-003 Blue Application Form _ EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON '�J04"Ae Day Ph �t ' " y Night Ph PwGRANI El-E,NIEN'1• W- `l C FEE ❑ Surcharge FEE ❑ Other FEE INs1Ec"rots# CICCU PERM("f VALID to ❑ Food Handler ❑ Check 4 AMOUNT PAID Date INVOICE# 11 Cash REVtEss'ED Bti'�o g111 ACCOUNTING OFFICE Date Masterfile Record Pink 48-0'-03.1 10/62003