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Ak <br />lr <br />• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID F -Ann (xg� "13 D _ _Program Record ID R -o S3L� (-73 <br />Facility Address Log <br />(Please Check the appropriate description and specify <br />FOOD PROGRAMS (1600) <br />number of units and pertinent information.) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ CommissaryElDry storage only Elwith Food Preparation <br />❑ Retail Market —Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle --Make <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility—Dates of operation <br />❑ Special Event —Dates of operation from <br />from <br />Food Handlers Course required:. YEs ❑ NO ❑ <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Vehicle Type <br />Color <br />License # <br />Sticker # - <br />Vch.icle Type <br />Color <br />License # <br />Sticker # - <br />to <br />to <br />❑ Ice Plant <br />❑ 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 />HAZARDOUS WASTE PROGRAM (2200) f <br />❑ Hazardous Waste Generator. — Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (221 S) ❑ Silver Only (2222) ❑ Appliance Recyclers (221 7) <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 R forms <br />HOUSING PROGRAM (2400) <br />El Ilotet/hlotel Number of Units DJail or Exempt Institution Number of Units <br />Employee housing (27 00) Use Fmployee fiorrsinKabor Caccp Applicafian Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local IAV Cleanup Site, ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HNV Site ❑ non-NPLJSEP Cleanup Site ❑ RNVQCB 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 Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds 11 Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4 120) ❑ 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 E]Transfer Station 11 Ag / Cannery Waste Site ❑ Studge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA -Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ Farm/Rauch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ,Large Generator 0 Small Generator ❑ Limited hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --11 2 - 10 ❑ I1 - 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use Pi/'SFHD 46-02-403 BlacApplicafion Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />CONTACT PERSON _ Day Ph Night Ph <br />PROGFZ4Rt ELEh1ENT_ k1530 __ FEE _ <br />INSPECTOR# a�aa _i PERMIT VALID <br />11 Check f: AntOUNT PAID <br />0 Cash-iiEVIEWEDBY <br />❑ Surcharge FEE . El Other FEE __ <br />I.tL to (�?�1) 11 ❑ Food Handler_ <br />_ _ _ Date INVOICE# �GS l <br />ACCOUNTING OFFICE Date 3 / /Z ( 1 <br />