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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERYILE RECORD INFORMATION FORM ❑New EH Program at Existing Facili y ew EH Program and New Facility Facility ID Pro ram Record IDE19,52 722 Facility Address3 — (Please Check the appropriate descrip ' n and specify s¢e number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food IIandlers Course required:. YES❑ No❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending 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 operatio from to ❑ Produce Stand DAIRY PROGRAM(20W) ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) 3 04—iazardous Waste Generator—Tons Generated Per Year ❑Recycle I Exempt System(2299) ❑ CRT Offsite Handl (221&) ❑ Silver Only(2222) 1 ❑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 forms HOUSING PROGRAM(2400) ❑ HotdfMotel Number of Units ❑Jail or Exempt Institution Number of Units Employee Ifousiag(2700)Use Fm to a llousin /labor Camp implication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑Environmental Assessment UST-CAP Site ❑Local I1W Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site W ❑Abandoned II Site 13 non-NPLISEP Cleanup Site ❑R'%VQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR.CONTROL PROGRAM( 000) ❑Poultry Farm Maximum n ber of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200 ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill 11Tra er Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Co post Facility ❑Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑Dumpsfers>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4 00) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited hauler ❑ Transfer Station []'VeterW ry Clinic ❑ Common Storage Facility--D 2-10 ❑ 11-60------❑>60 generators PUBLIC WATER SYSTEM PROC RAM(4600)Use PHSEIIP 46-02-003 Blue Application Foran MERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 0 FEE— 11 surchar FEE ❑ Other FEE INSFECTOR# P RM VALID (�JTp� to 02 �� ❑ Food handler ❑ Check# AM AID Date INVOICE# 11 Cash REVIEWED BY ACCOUNTING OFFICE Date