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SAN"JOAQUIN COUNTY EN 'ONMENTAL HEALTH DEPAR ANT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro am at Existing Facility ❑New EH Pro am and New Facili - <br /> Facili ID 0 D 0 D I 0 90 9 Program Record ID - 5 23�S <br /> Facility Address Ct <br /> (Please Check the appropriate description and specify size,number of nits and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity .Square Footage - Food Handlers Course required: YES ❑ -No❑ - - —- <br /> ❑ Commissary ❑ Drystorage 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 /> 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 <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy Cl Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) 2 27/ <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year— El Recycle/Exempt System(2299) <br /> 1:1CRT Offsite Handlers(2218) IJSilver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility — ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Pemtit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B farms <br /> HOUSING PROGRAM(2400) <br /> -❑ Hotel/Motel-------Number of Units ❑ Jailor Exempt Institution--Number of Units <br /> Employee Housing(2700) Use Employee Housine/Labor Cama Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment Cl 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(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <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--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---13 2-10------Cl 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON lFeA5 5CJt 4JSgn Day Ph 977 `W77 Night Ph <br /> PROGRAM ELEMENT Z ZZ l FEE SO ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 8377 PERMITVALID – O to - 11 Food Handler <br /> ❑ Check# AMOUNT PAID r c-LelDate INVOICE#' <br /> 11 Cash REVIEWED BY ACCOUNTING OFFICE 2a� Date 31-7 /o5-- <br /> 48-02-034 <br /> 7 OS48-02-034 - Masterfile Record Pink <br /> 10/6/2003 <br />