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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORKA.TION FOR11l ❑New EH Program at Existing facility xNew Eli Program and New Facility Facilit •ID - Program Record ID S3 L(- 3 (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD pEtOGRAhi(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Coarse required:. Yss El No ❑ CommissaryElEl with storage only ith Food Preparation ❑Fending Machines—Number ofUnits ElRetail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ElMobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary food Facility--Datcs of operation from to ❑ Ice Plant 11Special Event —Dates of operation from to El Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Bead Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) l ❑Hazardous iVaste Generator.-- Tons Generated Per Year ❑Recycle I 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 ❑Penriit-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 fauns HOUSING PROGRAM(2400) ❑ Ilotenjotel Number of Units -❑ Tail or Exempt Institution Number of Units Employee Ilousing(2700)Use Employee Ilousin£lla6or Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAI'Site ❑Local IIW Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site ® Abandoned ITV Site ® axon-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water 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) ElPoultry Farms Maximum number of birds 11 Kennel `TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑Body Piercing(4 120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) El pumper Vehicle—Registratioa# License it Capacity Vehicle# ❑ Pumper Yard ❑Package Treatment Plant" ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag I Caanery\Waste Site ❑ Sludge/Ash Site j Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑FarmfRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator Q Small Generator ❑Limited Hauler ❑ Transfer Station ❑Veteriaary Clinic ❑ Common Storage Facility--E] 2- 10 ❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)UsePl{`SEITD f6-02-003 BlacApplica6art Form EMERGENCY NOTIFICATION FORTKIs FACILITY ANQIOR PROGRAM CONTACT PERSON Day Ph Night Ph I'ROGRANIELE^NrIENT_�\Vl LQ ❑ SurchargCFEE - ❑ Other FEE _ INSPECTOR# ot1L�� PE MITVALID to ElFood Handler__ Nate 1tNOICE ❑ Cash l TVIL=�VLli BY )Q �) AcCOUNTING OFFICE _v__ _ =- _=----- --_