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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility ew EH Program and New Facility Facility ID 2i� Pro ram Record ID Pto Facility Address c:"J S 7_0 (Please Check the appropriate description and specify size number of units and pertinent information.) FOOD PROGRAM(1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required:.. YES No 11❑ Commissary ❑ Dry storage only 11with Food Preparation 13 Vending Machines-Number of Units ❑ Retail Market----Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility---•Dates of operation from to ❑ Ice Plant ❑ Special Event -Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Housim-Kabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site, 0 NPL/SEP Cleanup Site ❑UIC Site ❑Abandoned IiW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑P901 ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR.COHTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds 11 Kepe[�yyy-I TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent C 412Q LIQUID WASTE PROGRAM(4200) ✓pq �-009 7 ❑ Pumper Vehicle-Registration# License# Capacity # �l ❑ Pumper Yard ❑Package Treatment Plant" ❑ Chemical Toilets Number of UnitP F �FCOCi SOLID WASTE PROGRAM(4400) FNT ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles-Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator 11 Small Generator ❑Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PMS EFID 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON q� Day Ph Night Ph PROGRAM ELEMENT 1(0 Z FEE R o(J (A) ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 1 Icy 2-L-2- ERMIT VALID 41 2-7�0 1 to 41 -,,o1 11 Food Handler p C 11Check# V 1 8", AMOUNT PAID 4.2-(o 0. 0 D Date `f Y-I O INVOICE# 1�,q o J 11CashA o451 C PREVIEWED REVIEWED BY j ACCOUNTING OFFICE (,y�j Date +I xq p yfyra D: 1.