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f <br /> 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New Eli Program and New Facility <br /> Facilit ,ID - FAnh IS '7 Pro ram Record ID _�� <br /> Facility AddressD3 NuW1 �f ma <br /> (Please Check the appropriate description and specify size'number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail 112arket—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vchicle---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 ❑ Grade B Dairy ❑)Milk Dispenser—Numbcr of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IL47-ARDOUS WASTE PROGRAM(2200) a <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ 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 Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ notcl/htotel Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee housing(2700)Use Fmployee IfousirtzlEabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑ Local IIIV Cleanup Site. I ❑ NPLfSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLJSEP 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 Senice Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farm Maximum number of birds 11 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/Cannery Waste Site ❑ Sludge/Ash Site <br /> W Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ FarmiRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Ilauler <br /> ❑ Transfer Station ❑ Veterivary Clinic ❑ Common Storage Facility--E] 2- 10 ❑ 11 -60_--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P1KSF,ffD46-02-003 BlueAppficalion Form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY ANDIOR PROGRAM <br /> CONTACT PERSONDay Ph Night Ph <br /> PROGRAM ELEMENT qD 14 JJ,,V FEE � ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMITVAL1D to ❑ Food Handler <br /> ❑ Check# AmODUNT PAID + Date INVOICE# — <br /> ❑ Cash REVIEWEDBY ec 1o�711D ACCOUNTING OFFICE Date �� � <br />