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SAN JOAQUIN COUNTY . IRONMENTAL HEALTH DEPAR :NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID 1'5s S I Program Record ID <br /> Facility Address t t `)- W , t -0ST Tfl-" <br /> (Please check the appropriate des ription and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage o ly 1:1 with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footag 1:1 with Meat Market only El Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dat s of operation from to ❑ Ice Plant <br /> ❑ Special Event Dates of operati n from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ rade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surchar a(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Hazardous Waste Genator------------Tons Generated Per Year S ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2 18) -------------El Silver Only(2222) 1:1 Appliance Recyclers(2217) <br /> Tiered Permitting Facility ------------------❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ElPermit-By-RuleFixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> 1:1 ABOVEGROUND STO GE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STOR GE TANK(UST)PROGRAM(2300) Use UST A and B forms <br /> HOUSING PROGRAM(2400) 1 <br /> ❑ Hotel/Motel------Number of Unit ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing(2700) Use Em l ee Housin /Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM 3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000 <br /> ElPoultry Farm-------Maximum nu ber of birds El Kennel <br /> TATTOO BODY PIERCING PERMANE MATNET PROGRAM (4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Trans r Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Comp st Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of Units) ❑ Dumpsters >20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Car ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic El Common Storage Facility El - 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM 0600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE 2 j ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# S(oy 2 PERM T VALID 01 r 01 I l to 1-7-r?j 1 / 1 ❑ Food Handler <br /> ❑ Check# AMOUN PAID Date INVOICE# <br /> ❑ cash REVIEWED BY ACCOUNTING OFFICE Date l f f k !r <br /> PLL- I UL t�eG.NrJ N trJG' 101 ( . ov-fo <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/07 <br />