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yr <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> h•IASTERFILE RECORD INFORMATION FORM _ <br /> ❑ New Eli Program al Existiu Facility New EH Program and New I'acilil}_ <br /> Facility ID 0 0 Pro ram Record ID Ao 4 357/ <br /> Facility Address � a- o U <br /> (Please Check the appropriate description and speci y size,number of units and pertinent information") <br /> FOOD PROGRAM(1604) <br /> ❑ Restaurant: Seating Capacity Square Footage Food IIandlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending hlachiues—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Velticle Type Color <br /> Registration It License It Sticker It <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ 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 lvfulti-IIead Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ hazardous Waste Generafor-- Tons Generated Per Year ❑ Recycle I 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 ❑ Pemut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2304)Use USTA and R Lorms <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotel/1ltotel—Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee housing(2700) Use Fmplopee flousirtzlLabor Camp Appficaliorc Fomi <br /> SITE MITIGATION(2940) UNDERGROUND INJECTION CONTROL(3000) <br /> ElEnAronmental Assessment ❑ UST-CAF Site ❑ Local HW Cleanup Site• ElNrusEP Cleanup Site El UIC Sifc <br /> El Abandoned IIIV Site Elnon-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(300) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑ Out of Sen ice Poolfspa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds El 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 If License It Capacity Vehicle It <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag I Cannery Waste Site ❑ Sluder/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Itecycle Facility ❑ CIA Landfill Site <br /> Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ Farm/Ranch 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----E] 2-10 ❑ 11 -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff SFHD 46-02-003 rlrreApplicaliorn Furst <br /> EMERGEtICY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> P12UGRAm ELEMENT_ 4YNO FEE ❑ Surcharge FEE ❑ Other FEF, - <br /> INSrF.CTOR# &0�a PL•RNt17-VALID to ❑ Food handler__ <br /> ❑ Check _ AmouNT PAI) Date I14VOICl=It _ <br /> 0 Cash l:tviev!)_DLSY � _TLQ �� ArCOU?JrIr:GOrrtCE - Date - / ll/ <br /> ]Q _- =�1 —_ <br />