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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existin a Facility ❑New EH Program and Ness Facility <br /> FWIMI •ID 00033--9 Pro ram Record ID r <br /> Facility Address 'F,,.o% Si- <br /> ca - ,._ .. <br /> (Please Check the appropriate description and specify s_Lt7e number of units and ertinen(information"} <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required.. Yrs❑ No ❑ <br /> ❑ Commissary ❑ Drystorage 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---Mahe 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 froin = to <br /> El lee Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy 0 Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑hazardous Waste Generator. Tons Generated Per Year ❑ Recycle l Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility 0 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 B forms <br /> tIOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ©Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee X7ousin,-/Labor Camp Applicadon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPIJSEP Cleanup Site ❑RWQCB Cleanup We '0 Water Quality Remediation Site - <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out or service P901/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(4I21) ❑ Body Piercing(4 120) 0 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) V10 <br /> Pumper Vehicle—Registration#_LRT5_CAMSXjALicensc# �#3,3734 Capacity GO G Vehicle# - !S <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 /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Firm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Cart ❑Acute Care ❑ SI:ilIed Nursing ❑Large Generator Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--0 2- 10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use f ff S EFID 46-01-003 Blue A lication Form <br /> EMERGENCY NOTIFICATION FOR THOS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PRocRANiELl_n1ENT 192 yLl FEE ❑ SurcbargeFEF ❑ Other FEE <br /> INSPECTORPERMITVALID to ❑ FoodIlandler <br /> ❑ Check# AMOUNT PAIL) Date y INVOICE# <br /> Cash REVIEWED BY ACCOUNTING OFFICE Date a <br />