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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> Jid New EH Program at Existing Facility ❑New Eli Program and New Facility <br /> Facilit H) /Q �' Pro ram Record IDS <br /> Facility Address r, O� 1 n_VM a - <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food handlers Course required: Yes❑ No 11 <br /> ❑ Commissary El Dry storage only 11 with Food Preparation ❑Fending Machines—Number of Units <br /> El 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 11 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-liead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) a <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 AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑IloteUMotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Fmployee Ifousin*gabor Camp Appficalion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. I ❑NPIJSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ 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) <br /> ❑ Landfill 13 Transfer Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Iire Facility ❑ Compost Facility ❑ Process/Recycle 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 /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator [] Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHISF11D 46-01-003 Blue Application Foran <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> I <br /> PROGRAM ELEMEn'T L17 � FEE 11Surcharge FEE 11 Other FEE <br /> INSPECTOR# PERMIT VALID _— to ❑ Food Handler <br /> ❑ Check# A1110UNT PAID _ Date INVOICE# <br /> ❑ Cash REVIEWFD BY ACCOUNTING OFFICE _ _` Date <br />