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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program atExistin Facility ❑New EH Program and New Facility <br /> Facilit 'ID (-A g Q VM l Pro ram Record ID j :Q 53Y q <br /> Facility Address AigbrvtJ )' Q(Ik. 00-4 ( A g53.01 <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 /> ❑ 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 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—Dates of operation from to ❑ Ice Plaut <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 /> IIAZARDOUS WASTE PROGRAM(2200) 1 <br /> ❑ hazardous Waste Generator--- Tons Generated Per Year ❑ Recycle I Eacnrpt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pcmut-By-Rule Fixed Unit ❑ Pemut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK.(UST)PROGRAM(2300)Use USTA and B Lorrrrs <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Iiousing(2700)Use Fnrployee ffousinl'/Labor Camp Application Fom, <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Enviroamental Assessment ❑UST-CAP Site ❑ Local IPV Cleanup Site. ❑ NPL/SEP Cleanup Site 13UIC Site <br /> ❑ Abandoned IIW Site 11non-NPLJSEP Cleanup Site ❑R\VQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility - 11 Pool 11 spa ❑ Out of Service Pool(Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ 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 /> AWaste Tire Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ 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 Ilauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10 ❑ 11 -60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIKSFIID46-42-003 BlrrcApplica(ion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> i <br /> PROGRANt ELEMENT 1 r�'A FEE ❑ Surcharge FEE ❑ Other FEE <br /> n <br /> INSPECTOR# bbl PERMIT VALID to ❑ Food Handler <br /> ❑ Clieck# AMOUNT PAID Date INVOICE it _ <br /> ❑ Cash R.EVIEwED BY RE Ldsho ACCOUNTING OFFICE Date <br />