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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART M TNT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility "New EH Program and New Facility <br />Facilit • ID tl­ Program Record ID 5�2 74 <br />Facility Address � <br />(Please Check the appropriate description and specify E!�s number of units and pertinent information) <br />RECE �� <br />JA A/ <br />1 8 20p8 <br />NFq T f Dj� QR MENTI <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs ❑ No ❑ <br />❑Commissary ❑Drystorageonly ❑ 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 --Make <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility ---.Dates of operation it <br />❑ pedal Event —Dates of p�eraiion firm <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />Produce Stand <br />,�RY ROGRAM (2D00) <br />_ ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containersin Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) q <br />❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle f Exempt System (2299) <br />❑ CRT Offsite Handlers (2219) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility ❑ 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 />HOUSING PROGRAM (2400) - <br />❑ Hotel/Motel Number of Units ❑ Jail or Erempt Institution —Number of Units <br />Employee Housing (2700) Use F•mploree HHousino1abor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) _ <br />0 Environmental Assessment UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site, ❑ RWQCB Cleanup Site . ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑P901 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm—Maximum number of birds _ <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) - ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑Pumper Vehicle—Registration# License# Capacity Vehicle# <br />❑Pumper Yard ❑ Package Treatment Plant t ❑ Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag I CauneryWaste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA.Laudfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters> 20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --O 2 - 10 — ❑ 11 - 60 —❑ > 60 generators <br />❑ Spa 0 Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIIS F_IfD l6-02-003 Blue Application Farm <br />CONTACT <br />Day Ph <br />Night Ph <br />PROGRAM ELEDIENT — FEE 4ZA-�t� f�/��'D�Surcharge FEE ❑Other FEE <br />INSPECTOR # PERMIT VALID1---���d d to $1. yINVOICE # <br />❑ Food Handler (� <br />El Check # (a 2-� 3 AMOUNT PAID k o b r 67) Date \� W-1 () 6 V' f L-�/ <br />"6d cash REVIEWED BY ,SII ACGUUNTINGOFFICE Date ( <br />