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�r <br /> l <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH llEI'ARTII7ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Exisfiag.Facility ❑New Ell Program and New Facility <br /> 7�Facilit'ID t' Pro rani Record ID <br /> Facility Address v-113 fl­nffAclD <br /> (Please Check the appropriate description and specify sue,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No 11 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation 11 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 /> El 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—Numbcr of Containers in Multi-licad Unit <br /> CUPA ❑ State Facility Surdrarge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200)' I <br /> ❑ Hazardous Waste Generator— Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite handlers(2219) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2219) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Pemdt-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and R Lawns <br /> HOUSING PROGRAM(2400) <br /> ❑ notel/111otel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Frnployee ffousinglLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local MV Cleanup Site ❑NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned 11W Site ❑ non-NPI.JSEP Cleanup Site ❑R\YQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility -- 11 Pool ❑ Spa [.IOut of Sen ice Pool/Spa [INatural 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(412 1) ❑ 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 /> ,KYaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cuyd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited IIauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--El 2-10 ❑ 11 -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PII.SFIID 46-02-003 Blac Application Form <br /> EMERGENCY NOTIFICATION FOR THIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> I'llOGRAM ELENIENT1-17210 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID _ Date IN-voiCF,# <br /> ❑ Cash RF_VI6wEDBY ACCOUNTING OFFICE _ _ Date ? — <br /> . <br />