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4. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New Ell Program at Existing Facility <br /> ONew EH Program and New Facility <br />Facility ID Program Record ID Pi? f)(5-75.9 <br />Facility Address I 3, / / r yi: -5/.:- AA i i - t----] /9 t/ YV) tc)-Nr&.- eA <br />(Please Check the appropriate decription and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines —Number of Units <br />Retail Market —Square footage 0 with Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />ED Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Vehicle Type Color <br /> <br />License # Sticker # <br />CUPA El State Facility Surcharge (2399) <br />HA RDOUS WASTE PROGRAM (2200) i <br />Hazardous Waste Generator —Tons Generated Per Year 0 Recycle / Exempt System (2299) <br />0 Silver Only (2222) _ 0 Appliance Recyclers (2217) <br />0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 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 13 forms <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel --Number of Units 0 Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local IlW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 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 />El Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper Vehicle—Registration # License # Capacity Vehicle # <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag / Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 1:1 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles —Number of Units 0 Dumpsters > 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 />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility---0 2 - 10 — 0 ii - 60 ---C1 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use Pll'S ElfD 46-02-003 Mae Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDfOR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />Mobile Food Prep Unit—Make <br />Registration # <br />0 Temporary Food Facility —Dates of operation from to 0 Ice Plant <br />Special Event —Dates of operation from to 0 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 />El CRT Offsite Handlers (2218) <br />Tiered Permitting Facility <br />PROGRAM ELEMENT FEE FEE 0 Surcharge FEE <br />INSPECTOR # t•7 r PERMIT VALID . to 0 Food handler <br />0 Check # AMOUNT PAID Date INVOICE # <br />0 Cash REVIEWED BY ' ACCOUNTING OFFICE Date 7 & ...7 <br />0 Other FEE