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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> i�New EH Program at Existing Facility ❑New Ell Program and New Facility <br /> Facilif+ID r-A 00 V3S,h. <br /> Pro ram Record ID <br /> Facility Address Wil, kik Sa15 <br /> (Please Check the appropriate description and specify size,n tuber of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No 11 <br /> ❑ Commissary11Dry storage only 11with Food Preparation ElVending 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 /> El Temporary Food Facility—Dates of operation from to El ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> ITAZARDOUS 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 ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Housebold 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 /> ❑ hotentotel Number of Units .❑Jail or Exempt Institution--Number of Units <br /> Employee Housing(2700)Use Fmployee ffousim�lTebor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑Local MV Cleanup Site. ❑ NPLdSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑RIVQCB 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 13ODY 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 I Cannery Waste Site ❑ Sludge/Ash Site <br /> CA Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA,LandIll Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch 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--11 2-10 ❑ 11 -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIf:SF,TTD46-02-003 B[tie AppficationForun <br /> EMERGENCY NOTIFICATION FOR TF1ts FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE (d ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# a�9�� PEP.MIT VALID to El Food handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date ., <br />