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SAN JOAQUIN COUNTY ENVIRONAI ENTAL HEALTH DEPARTAZENT <br /> MASTERFILE RECORD INFOIU4ATION FORM <br /> ❑New EH Proram at Existing Facility ❑New Ell ProF4rn and New Facility <br /> Facility ID ? Program Record ID 'G <br /> Facility Address Z 3 2 S• U s <br /> (Please Check the appropriate description and specify s'Iz___,e number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food handlers Course required:_ Yes❑ No 13 <br /> ❑Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> 11Retail Market—Square footage ❑with Meat Market only [3Multiple 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 /> ❑Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(20W) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> IIAZARDOUS\VASTE PROGRAM(7200) i <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 ❑Pe y-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 foormsi L� <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units ❑Jail or Exempt Instr 'on--dumber of Units <br /> Employee II*asin g(27 00)Use F-MnloYee Ito usinp/La—bo r Camp Applicadeit Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local 11W Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned I1W Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathlug Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑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# License# Capacity Vehicle# <br /> ❑Pamper 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 /> ■ <br /> ❑Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsfers>ZO 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 Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility—[]2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use pfrS EfID*6-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Pb <br /> PROGRAM ELEMENT FEE ❑Surcharge FEE ❑Other FEE <br /> INSPBCr'OR#e &*4 PERMITVALID . to ❑Food Handler <br /> ■ ❑ Check# AMOUNT PAID Date INVOICE# <br /> 0 Cash REViEwEDBY ACCOUNTING OFFICE Date pc (� <br />