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-SAN'JOAQUIN COUNTY EN`. ONMENTAL HEALTH DEPA T <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ONeW EH Pro ram and New Facility <br /> Facility ID C7 u 1-7-70 1 Program Record ID P-0S-a-(� IS-9' <br /> Facility Address `j <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 11 No El <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Onl} <br /> ❑ Mobile Food Vehicle-----`fake 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 /> ❑ <br /> El Grade A Dairy 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------------------❑ Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous %Vast: <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use USTA and B forms <br /> HOUSING PROGRAM(2.100) <br /> ❑ Jail or Exempt Institution-------Number of Units <br /> El Ilotel/Motel-------Number of Units <br /> Emplo%cc Ilousing(2700) Use Employee HousinglLahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> El Environmental Assessment ElUST-CAPSite ❑ Local HW Cleanup Site ElNPL/SEP Cleanup Site 11 UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facili1% ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Kennel <br /> ElPoultry Farm --------- number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4 12 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) <br /> LIQUID WASTE PROGRAM(4200) <br /> License# Capacity Vehicle# <br /> ElPumper Vehicle -Registration# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) ?' <br /> ❑ Ag/Canner Waste Site ElSludge/Ash Site <br /> El Landfill -0 Transfer Station Y <br /> ❑ Process/Ree cle Facility ❑ CIA Landfill Site <br /> )1 Waste Tirc Facility ❑ Compost Facility } <br /> ❑ Dum sters>20 cu d----Number of Units ElFarm/Ranch Cleanup Site <br /> E] Refuse Vehicles--NumhcrofUnils __ P• y <br /> MEDICAL WASTE PROGRAM(4500) <br /> 1:1 Primary Care El Acute Care El Skilled Nursing ❑ Large Generator E3 Small Generator ❑ Limited Hauler <br /> El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility'- El 2- 10--- -- 11 1 I -60-- -- ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P;VS EHD 46-02-003 Blue Application Form <br /> _ EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON JG �� Day Ph LjJ ? `l 7 �i Night Ph <br /> PROGRAM ELEMENT 41-10 FEE ❑ Surcharge FEE ❑ Other FEE <br /> C/ ��, to ❑ Food Handler <br /> LNS1'I.C101t# ` ��U PERMIT VALID <br /> ❑ Check N AMOUNT PAID Date INVOICE# <br /> C1 Cash REVIE\\ B5'�f /i1 ACCOUNTING OFFICE Date >o <br /> ED <br /> Masterfile Record Pink <br /> 10/6 2UU i <br />