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SAN JOAQUIN COUNTY ENVIRONMMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility El New EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Address z1,, Zi? n r. <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❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending 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 It License# Sticker# <br /> El 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-Ifead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generafor. --- Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Per"tting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous`Paste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B corms <br /> HOUSING PROGRAM(2400) <br /> ❑ notenlotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Aousing(2700)Use Employee ILorrsine/Labor Camp Applica6orr Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site 13 Local MV Cleanup Site, ❑NPLISEP Cleanup Site 11 UIC Site <br /> ❑ Abandoned IIAV Site ❑ non-NPLISEP Cleanup Site ❑RNVQCB Cleanup Site ❑}Vater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY 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 /> 1 Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA•Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care El Acute Care ❑ Skilled Nursing 11 Large Generator El Small Generator ❑ Limited Battler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--11 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PN'SFKD 46-02-003 BlueApplica[ion Forret <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSONDay Ph Night Ph <br /> — - i <br /> I'R0GIL4h1ELEN1FNT_ E7 yD FEE ❑ Surcharge FEE ❑ Other FEE — <br /> INSPECTOR# 3� PEFMIT VALID __— to ❑ Food Handler <br /> El Chcckt, .AMOUI-r P.,kn) _ Date 11W010EI# — ---- <br /> E] Cash_L_--+ R-EV1EVIEDBY ----=—__ACCOUNTIidGOFFICE - --- ---nate 7 - <br />