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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFOMIATION FORM <br /> ❑New EH Program at Existin Facility KNew EH Program and New Facility_ <br /> Facility IDFy)qff 02 Pro ram Record ID -3 7 <br /> Facility Address 7 �"( <br /> (Please Check the appropriate description and specify sizenumber of units andTpertinent information.) <br /> FOOD PROGRAM(1604) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes 11 No El <br /> El Commissary <br /> Commissary ❑ Dry storage only with Food Preparation ❑Fending hlachincs—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 /> ❑ 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—Number of Containers in Multi-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) a <br /> ❑ hazardous Waste Generator-- Tons Generated Per Year El Recycle/Eaempf System(2299) <br /> ❑ CRT Offsite Handlers(2216) ❑ 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) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B fomts <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/111ote1 Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Fmpla yee Ifarrsin>Y/Labor Camp Applicafiorr Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local H\V Cleanup Site, ❑ NPLISEP Cleanup Site ❑UTC Site <br /> ❑ Abandoned HBV Site ❑ non-NPIJSEP Cleanup Site ❑RBVQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑ Pool ❑ Spa ❑ Out of Service Poo1/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑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 /> El Landfill El Transfer Station El Ag/Cannery Waste Site El Sludge/Aslr Site <br /> 19 Waste Tire Facility ❑ Compost Facility ❑ Process[Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch 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--E] 2-10 ❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use Plf'SFUID 46-02-003 BilueApplfcalion FOrm <br /> EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGrc,kmELENIE>''T '"I / At o FEE ❑ SurcbargeFEE ❑ Other FEE _ <br /> INSPECTOR# h]0.��to _ PEFMITVALID __— to ❑ Food handler_ <br /> Ej Chcck f: 'AATOU1 n- Date Ii7V0ICE/f _ <br /> ---- <br /> ❑ <br /> Date <br /> Cash 1 E','iEP/ED BY ACCOIJPaTI1dG OFFICE _—_ —_ <br />