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1 <br /> i <br />} <br /> SAN J'OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4 ' <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro am at Existing Facility, ®New El{Program and New Facility <br /> Facility ID F (�- Q Q a-6-122, Program Record IDr3s Z <br /> Facility Addres's S. /9�,fjop <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. Yes❑ No ❑ <br /> ❑ Commissary ❑Dry storage only ❑ with Food Preparation Oven din-Machines Number of Units <br /> ❑Retail Market---Square footage ❑with Meat Market only ❑Multiple Deparhnents ❑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 Dairy 0 Grade B Dairy ❑MilkDispenser-----Number of Containers in Multi-Head Unit <br /> 4` CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) 1. <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) Cl 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 /> ❑Hotei/Mo`tel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Em to ee HouE, /Labor eampApplicadon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONMOL(300W) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑non-NPWEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P901 ❑ Spa ©Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard ❑Package Treatment Plant• ❑ Chemical Toilets Number of units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑SludgelAsh Site <br /> ❑Waste Tire Facility 13 Compost Facility ❑Process/Recycle Facility ❑ CU,Landf ll Site <br /> ❑Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ FarnvRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑Stalled Nursing ❑Large Generator 0 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ l 1-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWSEHD46-02-003 Blue A IicarionForm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 12-.01 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �C�1 PERMIT VALID to ❑ Food Handler <br /> ❑ <br /> check-# AMowr PAID Date INvoIC> # <br /> ❑ Cash REVIF-WE0 BY �5 � O 1Q ACCOUNTING OFFICE Date 3 3 d <br /> kd�rlP�lr RrcnrA Pink <br />