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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at ExistingFacility ❑New EH Program and New Facility Facility ID DQ� ` D Program Record ID DE E-39- Facility Address f L 1 r b ' 'fi �X-7 (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES'�1 No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments[] Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) -------------❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility—---------—---—❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST) (2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B forms HOUSING PROGRAM(2400) ❑ HoteUMotel------Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ h Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑RI ❑ Refuse Vehicles I#of Units) ❑ Dumpsters>20 cu yd(#or Units) ❑ Fa nup Site MEDICAL WASTE PROGRAM(4500) 11Primary Care ❑ Acute Care 11Skilled Nursing ElLarge Generator 11Small GenerU911 ginvited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 03;41v ,8 11 > nerators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form yFENVIRO UlN CO EMERGEN Y NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM A�T/y a�pMENTq�NTy CONTACT PERSON )-(-:1 A Day Ph � � fight Ph gRTMENf� PROGRAM ELEMENT / FE E] SurchOr e F E 11 Other FEE INS ECTOR# 40 2-13 PERMIT VALID t0 `51-3 r' ;- ❑ Food Handler Ef Check# AMOUNT PAID Date 2 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date Z 2D 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07