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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE R&RD INFORMATION FORM <br /> ❑ New EH Pro ram at Existing FacilitX New Eli Program and New Facility <br /> Facility ID CC IS -E' Pro ram Record Ill <br /> Facility Address /0e�4 A -G k-,- <br /> (Please <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD_PROQrRAM(1600) <br /> ❑ Restaurant: Scaling C:apacily..__ . Square Foolagc __..--.--_- _ hood llandlers Course required: Ylts❑ 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 Vehicle-----Make Vehicle Type Color <br /> Rcgistration It Liccnsc it Sticker It <br /> ❑ Mobile Food Prep Unit--Make Vchicle Type Color <br /> Registration it License It Sticker It <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 /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WAS'T'E PROGRAM(2200) <br /> ❑ IIazardous Waste Generator------------`Ions Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Ilandlcrs(2218) ❑ Silver Only(2222) ❑ Appliance Rccycicrs(2217) <br /> Tiered Pa•u►itting Facility------------------ ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Pcrmit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILI'T'Y(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotcl/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee(lousing(2700)Use Employee IlousinglLabor Camp Alu/lication Foran <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ 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 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(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration It License It Capacity Vehicle It <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 ❑ 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------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EFID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT If-74) FEE _ 13Surcharge FEE_ 13 Other FEE <br /> INSPECTOR# 8636 PERMIT VALID_ 7 / U to &13 0 of ❑ Food Handler <br /> ❑ Chcck M AMOUNT PAID _ -11�— Date _ INVOICE# <br /> ❑ Cash R1;Vl1'.WIi11 nY ACCOt1NTIN<i OFFICE Date <br /> 48-02-034 Masterfile Record Pink <br /> 11/18/03 <br />