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y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM I)dNew EH Program at Existing Facility ❑New EH Program and New Facility Facility IDE/400 Pro ram Record ID Facility Address 1/0$0 jC C-r7b C/� . 570C 71n J-1 (Please Check the appropriate description and specify size number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ No❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑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) i ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle[Exempt System(2299) ❑ CRT Offsite Handlers(2219) ❑ 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 Housing/Laber Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑Environmental Assessment ❑UST-CAF Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RNVQCB Cleanup Site ❑Nater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ask Site K-NVaste Tire Facility 11Compost Facility 11Process/Recycle Facility 11CIA•Landflll 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 D Small Generator ❑ Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10 ❑ 11-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)UsePWSEHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT v FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# I!ZZ6 _ PERMIT VALID to ❑ Food Handler ❑ Check# AMO /'UNTPAID n Date INVOICE# ED Cash REVIEWEDBY PCI C)� d8 ACCOUNTING OFFICE Date 1p (,F