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SAN-JOAQUIN COUNTY EN'. __.ONMENTAL HEALTH DEPARTS vT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Proeram at Existing Facility ❑Neto EH Pro ram and New Facility <br /> Faciliri'ID r—A, C v L) (.q 7-7 Pro ram Record ID �-c7 SZ Io <br /> Facility Address 9', 77 S �` eoCo C c' m <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 El No El <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 -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 /> El Grade A Dairy 11 Grade B Dairy El Milk Dispenser --Number of Containers in Multi-Head Unit <br /> COPA ❑ 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------------------❑ 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 /> L'NDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Emplo}ee Ilousing(2700) Use Employee HousinglLahor Caron Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-GAP Site ❑ Local HNN'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pauls/Spas at Facilitt El Pool 11 Spa <br /> El Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11 Poultry Farm -------:Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 11 Tattooing(412 1) El Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) s <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Ree cle Facility El CIA Landfill Site <br /> ���'aste"fire Facility El Compost Facility )' y <br /> ❑ Dunt sters>20 cu d----Number of Units _ ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number ul'llnils ___ P� }� <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care El Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 02- 10- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMEN"1' fI j �L\ FFE ❑ Surcharge FEE ❑ Other FEF <br /> INSPECTOR# (,•C-� C' PERMIT VALID <br /> to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ CashREVIEtt'EDBS" �� .� �I_; ACCOUNTING OFFICE P'L'C Date <br /> Masterfile Record Pink <br /> 48-02-(j',4 <br /> 10/62 <br />