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f 116� SAN J"OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD-1NFORMATION FORM AZL.New EH Program at Existi2Z Facility ❑New Eli Program and New Facility Facilit ID ff}- $0113 Program Record ID Facility Address 6/ 5 (Please C heck the appropriate description and specify Sign,number of uatfs and pertineut information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES D No❑ ❑ Commissary D Dry storage only D with Food Preparation ❑A'ending Machines Number of Units 0 Retail Market---Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only ❑Mobile Food Vehicle—Make Vehicle Type Color Registration# License# Sticker# © Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility----.Dates of operation from to D Ice Plant ❑Special Event —Dates of operation from to l] Produce Stand DAIRY PROGRAM(20W) ' ❑ Grade A Dairy CI Grade B Dalry D Milk Dispe aser Number of Containers in Multi-Head Unit �i CUPA D State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200)' t ❑hazardous Waste Generator. Tons Generated Per Year _ D Recycle I Exempt System(2299) ❑ CRT Offsite Handlers(2219) !7 Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility - ❑Conditionally Authorized(CA) D Conditionally Exempt(CE) 0 Permit-By Rule Fixed Unit f❑Permit-By-Rule Household Hazardous Waste D ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and ft forms HOUSING PROGRAM(2400) 0 Rotel/Motel Number of Units D Jail or Exempt Institution Number of Units Eionployee Housing(2740)Use Em to ee 0ousin /Labor Cam Applicadon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000} ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. D NPLISEP Cleanup Site ❑UIC Site ❑Abandoned HW Site D non-NPLISEP Cleanup Site 13 RWQCB Cleanup Site ©Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑Pool D Spa D Out of service Pool/spa ❑Natural Bathing Area VIrCTOR.CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds D Kennel TATTOO,130DY PIERCING,PERMANENT_COSMETIC PROGRAM(4100) D Tattooing(4121) ❑Body Piercing(4120) D Permanent CosmeQ(4122)LIQUID WASTE PROGRAM(4200) N$iS91�umper Vehicle--Registration# �� Lacense# t� 3 Capacity�5�� VeE7 . D Pumper Yard D Package Treatment Plant- ❑Chemical Toilets Num er of Units SOLID WASTE PROGRAM(4400) ❑Landfill D Transfer Station ❑Ag/Cannery MVaste Site D SludgelAsh Site D Waste Tire Facility 0 Compost Facility D Process/Recycle Facility ❑ CIA,Landtill Site D Refuse Vehicles Number of Units D Dumpsters>20 cu yd Number of Units D FarmlRanch Cleanup Site MEDICAL.WASTE PROGRAM(4$00) D Primary Care Cl Acute Care ❑Stalled Nursing D Large Generator D Small Generator ❑Limited Hauler ❑Transfer Station 17 Veterinary Clinic D Common Storage Facility--13 2.10 ❑ 11-60—0>60 generators PURLI 0 WATER SYSTEM PROGRAM(4600)Use PWS ERD 46-02-003 Blue Annlicadan Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 41 FEE p o ❑ Surcharge FEE ❑ Other FEE INSPECTOR# O PERMIT VALID t0 ❑ Food Handler ❑ Check 9 AMOUNT PAID Date INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Date