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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New Ell Program at Exi-sting Facility ❑New EH Program and New Facility <br /> vacilit �ID D fly-, D Program Record ID (ZC S3 �o <br /> Facility Address 3 2TF Z <br /> (Please Check the appropriate description and specify sizenumber of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 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# License# Sticker# <br /> ❑Temporary Food Facility----Dates of operation from to ❑ Ice Plant <br /> [3 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 /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS'NVASTE PROGRAM(2200) <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 /> OUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employ"Iiousiag(2700)Use Employee Housinp/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) <br /> ❑ Environmental Assessment ❑UST-CAP Site 11 Local HW Cleanup Site, L1NPUSEP Cleanup Site 11 UIC Site <br /> ❑Abandoned RW Site ❑non-NPUSEP 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 Farrar Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4)21) ❑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 /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle 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 0 Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑.Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHISEAD 46-02-003 Blue Application Form <br /> EMERGENCY NOTMcATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT_ �(7y 0 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# "�7-,/ PERMIT VALID to ❑ Food Handler <br /> ❑ Check it ! AMOUNT PAID Date INVOICE# <br /> [I Cash REVIEWED BY ACCOUNTING OFFICE Date <br />