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SAN JOAQUIN COUNTY ENVIRONMENTAL IIEA.LTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New Ell Program at Existing Facility ew EIl Program and New Facility <br /> Facility ID Program Record ID i'K U <br /> Facility Address 10S�S ''� <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Square Footage Food handlers Course required: Yes❑ No El <br /> ❑Restaurant: Seating Capacity Sq g <br /> [ICommissary ❑ Dry storage only Elwith Food Preparation ❑\'ending 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 /> Sticker# <br /> Registration# License# <br /> Color Type <br /> ❑ Mobile Food Prep Unit—Make Vehicle Sticker# <br /> ❑ <br /> Registration# License# <br /> - to Ice Plant <br /> ❑ Temporary Food Facility—Dates of operation from ❑ Produce Stand <br /> ❑ Special Event —Dates of operation from It <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in/M"ult�i-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) ve/ <br /> HAZARDOUS WASTE PROGRAM(2200) / I <br /> (4I1azardous Waste Generator-- Tons Generated P r Year S 11 Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only_ <br /> nl ( 2) ❑ Appliance Recyclers(2217) <br /> in Facility ❑Conditional d(CA) ❑ Conditionally Ext t(CE� <br /> Tiered Permitting y <br /> ❑Permit-By-Rule Fixed Unrt M Permit-Ry-RUo�ehold Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> Number of Units Jail or Exempt Institution Number of Units <br /> ❑ IloteUhlotel <br /> Employee Ilousing(2700)Use Fmpfoyee Ilousine/1',abor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPLISEP Cleanup Site [I UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa [3 Out of Service Fool/Spa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle <br /> El Pumper Vehicle—Registration# License# Capacity <br /> [I Pumper Yard 11 Package Treatment Plant El Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> El Landfill El Transfer Station 13 Ag/Cannery Waste Site b <br /> ❑Process/Re cle Facility ❑ CIA Landfill Site <br /> [I Waste Tire Facility 11 compost Facility cY y <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd--Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> [3 Primary Care 11 Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator 13 Limited Hauler <br /> >GO generators <br /> 11 Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---❑ 2-10 ❑ 11-60---❑ <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P111S FIID 46-02-003 Blue Application Form <br /> l EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR P <br /> RP <br /> CONTACT PERSON Day Ph 5 10 ght Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 7(ems 0 PE£.MITVALID . <br /> to ❑Food handler <br /> ❑ Check# AMOUNT PAID Date INVOICE <br /> ❑ Cash REVIEWED BY {�/� ACCOUNTING OFFICE Date <br />