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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORDINFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID .�- C7 d40� j� Pro ram Record ID RO 5 3 \1 D Facility Address (Please,Check the appropriate description and specify Ejj�,numberlof units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Courser -Nuired Yrs❑ No❑ ❑ Commissary ' 13 Dry storage only 11with Food Preparation 11Vending Machines—Number of Units ElRetail Market----Square footage ❑with Meat Market only ❑ Multiple Departments ❑Prepackaged Goods Only h ❑Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# f ❑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(200 ) ❑ Grade A Dairy ❑Grade B Dalry ©Milk Dispenser---Number of Containers in Mutti-Head Unit Y CUPA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200)1 t ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) ❑CRT Offsite Handlers(2218) ©Silver Only(2222) v ❑Appliance Recyolers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-•I3y--Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and_$Jorm HOUSING PROGRAM(2400) ❑Rotel/Motel Number of Units "❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Em to ee Housin /Labor Camp R licafiou Form SITE MITIGATION(2.900) UNDERGROUND INJECTION CONTROL( 000 ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site ❑Abandoned RW Site ❑non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out or service Poouspa ❑Natural Bathing Area # VECTOR.CONTROL PROGRAM(4000) 0 Poultry Farm Maximum number of birds ❑Kennel 7 ATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) __0__q3 Pumper Vehicle--Registration# License Capcity,:M Vehicle# �S ❑Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag 1 Cannery Waste Site ❑Sludge/Ask Site ❑Waste Tire Facility ❑Compost Facility ❑ProcesslRecycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑FarnuRaneh Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EMD 46-02-003 Blue AoPlication Form EMERGENCY NOTIFICATION Fort THIS FA ILITY ANDIOR PROGRAM CONTACT PERSON moi/ Day P I �14ht Ph PROGRAM ELEmEN r �o�J' FEE ��. 00 13 $urcLarge FeE " ❑ Other FEE INSPECTOR# ✓I PERMIT VALID . [ `d t0 ?�� 3\ ( 0 13 Food handler F-1 Check# AMOUNT PAID )m� w•` Date INVOICE# ❑ Cash REVIEwEDBX ACCOUNTING OFFICE Date \` 2 31 C 1