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• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTAIENT <br />MASTERFILE RECORD INFORMATION FORM <br />New Eli Program at Existing Facility [New EH Program and New Facility <br />Facility ID fr. Program Record ID PR T7'/7 7 <br />Facility Address g* E Lout t &d- Pnie1.1 a 6 I 01A-rriEr-A <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation DVending Machines —Number of Units <br />0 Retail Market —Square footage 0 with Meat Market only D Multiple Departments 0 Prepackaged Goods Only <br />O Mobile Food Vehicle ---Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit—Make Vehicle Type Color <br />Registration # License # Sticker # <br />O Temporary Food Facility —Dates of operation from to 0 Ice Plant <br />Special Event —Dates of operation from to El Produce Stand <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser—Number of Containers in Multi-Head Unit <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Erliazardous Waste Generator Tons Generated Per Year 4 S-1121 0 Recycle / Exempt System (2299) <br />El CRT Offsite Handlers (2210 0 Silver Only (2222) 0 Appliance Recyclers (2217) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) El Conditionally Exempt (CE) <br />El Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />0 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 />0 Hotel/Motel —Number of Units 0 Jail or Exempt Institution —Number of Units <br />Employee Rousing (2700) Use Employee HousineLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local IIW Cleanup Site, 0 NPUSEP Cleanup Site 0 UIC Site <br />Abandoned IIW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Ste 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Tattooing (4121) El Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper Vehicle—Registration # License # Capacity Vehicle # <br />El Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station El Ag / Cannery Waste Site 0 Sludge/Ash Site <br />CI Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles —Number of Units 0 Durnpsters >20 cu yd —Number of Units 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Cl Transfer Station 0 Veterinary Clinic 0 Common Storage Facility—El 2- 10-011 -60 ---0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PI'S Elf1) 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph CONTACT PERSON <br />PROGRAM ELEMENT 22-72--C-, FEE 0 Surcharge FEE <br /> <br />AMOUNT PAID Date <br />to ale 116'9 <br />0 Cash REVIEWED BY <br />ACCOUNTING OFFICE <br />Other FEE <br />Food handler <br />INVOICE it <br />Date <br />INSPECI-OR Z-Cor? 0 PERMIT VALID . /9/// b9 7 <br />LI Check #