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SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> El'Nev,/ EH Program at Existing Facility —)&e,�,v EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Address 2.-i�2- <br /> (Please check the appropriate description and specify size. nurnber of units and pertinent information.) <br /> FOOD PROGRAM (16OO) <br /> [] Restaurant, Seating Capacity_____ Square Footage Food Handlers Course required: YES 11 Nn [] <br /> [] Commissary [] Dry storage only [] with Food Preparation []VendingMachines NomherofUnits <br /> [] Retail Market----Square footage [] v/Moat Market only [] Multiple Departments [] Prepackaged Goods Only <br /> [] <br /> Mobile Food Vehicle--Make Vehicle Type Color <br /> R*g|n1xmdon# Licenno# Sticker <br /> [] <br /> Mobile Food Prep Uni�'Make Vehicle Type ������----- Color <br /> Registration# Liconoo# SUcho,# ����--------- <br /> LJ <br /> Temporary Food Facility--Dates of operation from to [] Ice Plant [] Produce Stand <br /> [] <br /> Special Event---Dates ofoperation from to [] CFO [] A [] B <br /> DAIRY PROGRAM (zonn) <br /> [] Grade ADairy [] Grade BDairy .[] Milk Dispenser-Number ofContainers inMuV|'HeadUnit <br /> _____ <br /> CUPA <br /> [] Hazardous Materials Business Plan (19OO) NumUernfchemica|s- <br /> LJ Ca|ARP Program [] Program 1 Facility [] Program 2 Facility [] Program 3 Facility <br /> �~ <br /> ~�� <br /> ,= .azardouoVYastoGonerator (22OO)------- Tons Generated Pei Year <br /> [] Tiered Permitting Facility-------^ [] CA 12232} [] CE (2233, 2234. 2235 22371) 171 PBR (2231) [] PBR HHVV '22361 <br /> [] Aboveground Storage Tank Facility (A8T) (28OU) NumberofASTo________ <br /> [] Underground Storage Tank Program (UST) (2300) Use <br /> [] Od`e,oUPA Program <br /> HOUSING PROGRAM (24OO) <br /> [] Hotel/Motel------Numbp/of Units [] Jai/ or Exempt Institution ----NmnberofUnits <br /> _________ <br /> Employee Housing (27OO) Use Employee HousinglLabor Camp Application Form <br /> SITE MITIGATION (2300) UNDERGROUND INJECTION CONTROL <3000/ <br /> [] Environmental Assessment [] UST'CAPSite [] Local HVVCleanup Site [] NPL/SEP Cleanup Site [] U|C Site <br /> [] Abandoned HVVSite [] non-NPL/SEP Cleanup Site [] RVVOCB Cleanup Site [] Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM \500O' <br /> NumherofPools/Spas at Facility [] Pool [] spa [] Out ofService Pool/Spa [] Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4U0O) <br /> [] Poultry Farm-------Maximumnumber ofbirds [] Kennel <br /> TATTOO. BODY PIERCING.PERMANENT COSMETIC PROGRAM (4100' <br /> LJ Body Art Practitioner Reg (4110 [] Mechanical DSP8Notification (4115) [] Body Art Facility-Single Use (4120) <br /> [] Body Art Facility-Sterilization <4121> [] Body Art Temp Event Co'on1 (413O) [] Body Art-Temp Event Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM 42OO) <br /> [] PumperYohio|aRegiskuiun# License# — Capacity Vehicle# <br /> O Pu/nporYord O Package Treatment Plant O Chemical Toilets —NUmbei of Units <br /> SOLID WASTE PROGRAM /4*O0 <br /> [] Landfill [] Transfer Station [] Ag/Cannery Waste Site [] S|udgoA\nhSi»e <br /> [] Waste Tire Facility [] Compost Facility [] Process/Recycle Facility [] CIA Landfill Site <br /> [] Refuse Vehicles (*c,u"x^) [] Dumpstora> 20nuyd #xuv,s [] Fonn/RanohCleanup Site <br /> MEDICAL WASTE PROGRAM (45OO) <br /> [] Primary Caro [] Acute Care [] Skilled Nursing [] Largo Generator [] Small Generator [] Limited Hauler <br /> [] <br /> Transfer Station [] Veterinary Clinic [] Com/non Storage Facility [] 2 ' 10 [] 11 OO [] p 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use Fnm/ <br /> E16ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAF01 <br /> CONTACT PERSON Day Ph Night Ph <br />