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SAN-JOAQUIN COUNTY EN _.ONMENTAL HEALTH DEPARTWT <br /> T <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing FacilitX ew EH Program and New Facility <br /> Facilitv ID FjA Jv 1 —7 (:=,�ocj Pro ram Record ID <br /> Facility Address V 6�c�"`fi �` ' R14. <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No 1:1 <br /> ❑ Commissary ❑ Dry storage 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 -`flake 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 /> El Grade A Dairy C1 Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility------------------El Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of:QST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Lse UST A and B forms <br /> HOUSING PROGRAM(2.100) <br /> ❑ Ilotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> F:mplo}ee Ilousing(2700) Use Employee Housing/Labor Cany!Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11 Environmental Assessment El UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC site <br /> 11 Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site C1 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Nufmber oPools/Spas at Facility El Pool 11 Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm -------%laximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4 100) <br /> El Tattooing(4121) El 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 /> El ❑ Process/Ree cle Facility El CIA Landfill Site <br /> WasteTire Facility ❑ Compost Facility }� y <br /> ❑ Dum istcrs>20 cu d----Number of Units _ ElFarm/Ranch Cleanup Site <br /> El Iicfuse Vehicles--Number of Unils I� ' - }� <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator El Small Generator 1:1 Limited Mauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----112- 10-- - El I I -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P{VS EHD 46-02-00.3 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON O( N(UtS Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INShEUOR# C'R ,r, <br /> PERMIT VALID to ❑ Food Handler <br /> ❑ Check k AMOUNT PAID Date INVOICE# <br /> El Cash REVIEWED B1" ,� � Q? ��,� <br /> ACCOUNTING OFFICE ' L- Date —( ( Zl C) <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/201)1 <br />