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t `a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL REALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> E3,New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ID 0 O Vh Q�3 Program Record ID ` <br /> Facility Addles -76 L <br /> (Please Check the appropriate description and spec�-Vnnumber of units and pertinent information.) <br /> FOOD PROGRAM(i 600) <br /> D Restaurant: Seating CapacitySquare Footage Food handlers Course required:. YEs❑ No❑ <br /> D Commissary ❑ Dry storage only ❑with Food Preparation DVendiag Machines Number of Units <br /> ❑Retail Market---Square footage ❑with Meat Market only ❑ Multiple Departments 11 Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Maks 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(2000) ' <br /> ❑ Grade A Dairy ❑Grade B Dalry ❑Mill:Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2240)" i <br /> ❑Hazardous Waste generator. Tons Generated Per Year ❑Recycle 1 Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) Cl Conditionally Exempt(CE) <br /> ❑Permit-By Rule Fined Unit r❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ifot&Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employse Hoasiag(27110)Use F,_mplovee Hoavin z4abor Camp Applim on Form <br /> SITE MITIGA'T'ION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local UW cleanup site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPLNEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. 0 Pool ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VI=CTOR.CONTROL PROGRAM!(4000) <br /> 11 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) �%:T I aoy 19 -- <br /> ®Pumper Vehicle Rense <br /> —Registration#I��� Lic # S�� 7y Capacity lv� vehicle# 0,`f <br /> ❑ Pamper yard ❑Package Treatment Plant. ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag I Cannery Waste Site ❑ SludgelAsh Site <br /> ©NVaste Tire Facility ❑ Compost Facility ❑ProcesslRerycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse vehicles Number of Units ©Dumpsters>21)cu yd—Number of Units ❑ Farm%sucb Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Sldiled'Nursing ❑Large Generator Cl Small Generator ❑Limited Ilauter <br /> ❑ Transfer Station ❑Veterinary Clinic ❑Common Storage Facility-----O 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS FHD 46-02-003 Slue Apj!ficalion Form <br /> EMERGENCY NOTWICATION EOR TNIS FACILITY AND1011 PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELFNIENT�1-J 9 FEE ❑ Surcharge FEE .. ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to D Food Handler <br /> D Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />