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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ew EH Proam at Existing Facility ONewEIlProgMandNewFaciliLy Facilit ID f/,� Pro ram Record ID Facility Address (Please heck the appropriate description and specify E!K�,number of units and pertinent information,) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food handlers Course reµguired_. YES❑ No❑ ❑ Commissary ❑Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units ❑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 ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand t DAIRY PROGRAM(2000) ❑Grade A Dairy ❑Grade B Dairy ❑Mill:Dispenser---Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) ❑Hazardous Waste Generator-- Tons Generated Per Year ❑Recycle f Exempt System(2299) ❑ CRT Offsite Handltsrs(2218) ❑ SilVer Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B form HOUSING PROGRAM(2400) ❑Hotel/Motel Number of Units -❑Jail or Exempt Institution Number of Units Employed Housing(2700)Use Emproyee Housia&yAbor Camp rtppricaliort Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTR06(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site• ❑NPLlSEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑ non-NPIISEP Cleanup Site ❑RIYQC13 Cleanup Site •❑!Vater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Poois/Spas at Facility. ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathlag Area VE.C'rOR.CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200)'Z��51- �� limper Vehicle--Registration# License# Capacity Vehicle# ❑ Pumper Yard Ef Package Treatment Plant, ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag/CanneryWaste Site ❑Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ C1AiLandrill Site ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care 0 Acute Care ❑ Sinned Nursing ❑Large Generator Q Small Generator ❑Limited Hauler ❑ Transfer Station ❑Yeterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11-60—❑>60 generators PUBLIC WATER_ SYSTEM PROGRAM(4600)Use PIVS EHD 46-02-003 Blue Application Form EMERGENCY NoTiriCAT10N Fop THis F CILITY ANDtOR PPRROOPROGRAMCONTACT PERSON Day 9/� 6r 0 7'-�da gbt Ph PROGRAMELEMEN'T l'� { FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# ._53�� PERMIT VALID . to ❑Food Handler ❑ Check* AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED SY ACCOUNTING OFFICE Date