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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT it <br /> _MASTERFIL_E RECORD INFORMATION_FORM - __ <br /> ❑�Ne�a EH Program at Existing Facility_ _ _ _ IxNew EH Program and New Facility <br /> Facility IDD� � _ Program Record ID <br /> t---- - _--_---�- s -- <br /> Facility Address 2b2- q5 36� <br /> (Please check the appropriate description and specify size. number Of units and pertinentfTtS ornnation.) <br /> FOOD PROGRAM('1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ kvith Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ [ALIltiple 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 ❑ Ice Plant ❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in MUlii-Head Unit <br /> CUPA <br /> Hazardous Materials Business Pian (1900) Number of chemicals: <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator (2200)------------ Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA (2232) ❑ CE (2233, 2234 2235. 2231) ❑ PBR (2231) ❑ PBR HHW (223(3) <br /> ❑ Aboveground Storage Tank Facility (AST) (2500) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM ;2400) <br /> ❑ Hotel/Motel------NUmber of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <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 (4 100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130 ❑ Body Art-Temp Event Mobile Facility (4131) <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 /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (=of uniisl ❑ DUmpsteis> 20 cu yd �c`o',.ts, ❑ Farrn/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Harder <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 1 1 - 60 ❑ > 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PVVS EHD 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��Z�_ FEE ❑ Surcharge FEE ❑ Other FEE <br /> I,l <br /> INSPECTOR# PEFI✓IIT VALID to ❑ Food Handler <br /> ❑ Check.=! AMOU 4T PAID ! Date iNVOi�:E## <br /> j' ❑ Cash REVIE�.EDBY --___ F'_"l'r_I�JGOFFICE- — — Date <br /> FILE EC-'P. C'ELl.=T1 N PiP:F <br />