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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility []New EII Program and Neiti,Facility <br /> Facilit ID f—>-'V-a v�l03 � Pro ram Record ID (Zo 53 S <br /> Facility Address 3 aK, R 0,�.Cr,1 I ? <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 ❑Pending 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 /> []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-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) a <br /> ❑ Ilazardous Waste Generator---- Toru Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite 11andlers(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 /> ❑Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee ffousinz/Labor Camp Applieadon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IlW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC site <br /> ❑Abandoned HW Site ❑non-NPLISEP 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 PoollSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO 13ODY 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 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> j Waste Tire Facility 11 Compost Facility 11Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch Cleauup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care 11 Skilled Nursing 11 Large Generator ❑ Small Generator [I Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---[] 2-10 ❑ 11-60-- -❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PII'SEIfD46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEh1ENT lj 4 U FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID . to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE#I <br /> ❑ Cash REVIEWED BYL� ACCOUNTING OFFICE Date Gv <br />