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SAN JOAQUTIN COUNTY ENVIRONMENTAL HEALTH DEPARTIIIENT <br /> MASTERFILE RECORD-INFORMAnON FORl1I <br /> ❑New EH Program at Existing Facility w EH Program and New Facility <br /> Facility ID O 0 ,2-- — S Program Record ID ©-3-7c) <br /> Facility Address � i� '�r <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food handlers Course required:. Yes❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only El with Food Preparation ❑Vending Machines—Number of Units <br /> El Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ElMobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> El Temporary Food Facility—Dates of operation from = to El Ice Plant <br /> ❑ 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 /> HA7.ARDOUS`i'ASTE PROGRAM(2200) f <br /> ❑hazardous Waste Generator..— Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> [I Petnvt-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 /> ❑ Rotel/Motel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee Iiousin d(2700)Use Fmplopee HousinzlLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local TIN Cleanup Site, ElNPLISEP Cleanup Site 11UIC Site <br /> 11 Abandoned HAY Site 13non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PoolslSpas at Facility. ®Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ®Kennel <br /> TATTOO 13ODY 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 /> 11 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 ❑PrecesslRecycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator 10-&Mail Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P f'SERD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGrumELE&iENT yS3 FEE ❑ Surcharge FEE - ❑ Other FEE — <br /> INSPECTOR# �26—Q-C> _ PERMITVALID to ❑ Food Handler_ <br /> /15-c>c> AmOUNT PAID -- — — Da.te IINOICE# _--- <br /> ❑ Cash REVIEWED BY Accoutmw,OFFICE __ Date S"( h 2-- —_�� <br />