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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA-RTM . MASTERFILE RECORD INFORMATION FORM XNew EH Program at Existing Facility ❑New EH Program and New Facility Facility ID r' 2,5 Program Record ID S3< Facility Address (4'7a0LI E Fr�ma� �4_. SR-15- (Please Check the appropriate description and specify sue,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Stating Capacity Square Footage Food Handlers Course required:. Yes❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending 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(20W) ❑ 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) ❑Pcrmit-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 Ilousiag(2700)Use F,mployee ffousine%Laber Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site, ❑NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned 11W Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P901 ❑ 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(412 1) ❑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/Ash Site Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ FaravRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2- 10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use Pll'S FAD 46-02-003 BlueApplieafion Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRANi ELEMENT q ;-/() — FEE _ ❑ Surcharge FEE ❑ Other FEE — INSPECTOR# � PERMIT VALID` _ to_— _ _ ❑ Food handler_ eSNOUNTPAID 1 C� ti P J(E'NI')uy + ._. .,�.. ..,.n.. _m..,.-.,�.,.,,�,.=,,a,...,,,�..,.. ,,.U._�..,_mss.......,,,.....,.-,,.,.. ., �._,,. _ i•_.---�-..z.;..-...�'�, ...v�,v ,�; -.,a,.s==�-._--_:_ .,