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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID /L OCX7 Program Record ID k-0 5-3 S-7 <br /> Facility Address ?<=3 �` M <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:. Yrs❑ No ❑ <br /> ❑ Commissary11Dry storage only ❑with Food Preparation ❑Vending 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 /> ❑ Special Event —Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(200 ) <br /> ❑ Grade <br /> aaA,, Dairy E3 Grade B Dalry 13 Milk-Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA Y4tate Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> 'Vj�Ilazardous Waste Generator. Tons Generated Per Year a ❑Recycle I 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 /> ❑Petmit-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 /> ❑HoteuMotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housiag(2700)UseEmplevee Housinp/Labor Camp A 2ficatiorn Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL( 000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IINY Site ❑non-NPLJSEP 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.COHTROL 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 /> ❑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 /> ❑NVaste Tire Facility ❑ Compost Facility ❑Process/Recycle 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 ❑Skilled Nursing ❑Large Generator D Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10—1111-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'S EfID 46-02-003 Blue Application Form <br /> rPR0G_-RAm <br /> //��__ �EMERGENCY NOTIFICATION FOR THIS F ILI AND/OR PROGRAM //T PERSON .C�t.Jf! Day P �5 S Night I?IIAX;ELEMEN FE ❑ Surcharge EE ❑ Other FEE <br /> '70 PERMIT VALID . to /02 ❑Food Handler <br /> # NTPAID ® Date / © INVOICE# ,,REVIEWED BYI-op /�G OUNTING OFFICE to (' V <br />