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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART NT <br /> MASTERFILE RECORD INFORI`IATION FORM <br /> New EH ProEam at Existing Facility ❑New•EH Pro am and New Facility <br /> Facilitv ID FA00c&4cl5 Program Record ID <br /> Facility Address t-"- L.o D t <br /> (Please Check the appropriate description 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 only ❑ 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 Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator------------Tons Generated Per Year < S" El Recycle/Exempt System(2.2 99) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility-------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fired Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITN'(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/ivlotel-------Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee housing(2700) Use Employee Housing/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 ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 1:1 Pool 11 Spa ❑ Out of Service Pool/Spa C3 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Kennel <br /> ❑ Poultry Farm-----Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) El Body Piercing(4120) El Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> License# Capacity Vehicle# <br /> ❑ Pumper Vehicle--Registration# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill El Transfer Station C1 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd---Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> F-1PrimaryCare El Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> 11 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------El 11 -60—---- >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVSEHD 46-02-003 B/ueApplication Forni <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 2220 FEE <br /> r ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID I I U to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID I t.L, Date <br /> INvolcE <br /> 11 Cash REVIEWED BY ACCOUNTING OFFICE - Date �7�6 <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />