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SAN JOAQUTIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORII'IATION FORM <br />New EH Program at Existing Facility Mew Eli Program and New Facility <br />Facility ID % Alm iLIZ/.� �%Program Record ID {& 73-7c� <br />Facility Address /eve <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 Elwith Food Preparation ❑Vending Machines —Number of Units <br />F-1 Retail 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 <br />❑ Special Event —Dates of operation from to <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000 <br />❑ ❑ <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) I <br />❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle I Exempt System (2299) <br />❑ CRT Offsite Handlers (221 s) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Pcrrnit-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 (arms <br />HOUSING PROGRAM (2400) <br />❑ IlotellMotel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Iiousing (2700) Use Employee lfoasinelLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local I1W Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned IIW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Nater Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 11 Pool ❑ 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 I Cannery Waste Site ❑ Sludge/Ash Site <br />VLWaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ Farm/Rauch 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 -0 2 - 10 -- ❑ 11 - 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PI1:4EffD 46-02-003 BlueApplicalion Foran <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />Day Ph Night Ph <br />PROGRAM ELENIENT n(7 FEE _ <br />INSPECTOR# C14CX PGRMITVALID <br />1] Check g AnfOUNT PAIL) _ _ <br />0 Cash P.EVIEWEDBY <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # <br />Date W.�/I, 17 <br />