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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />EH Program and New <br />Record ID <br />Facility Address 53c�P. Pl/ c 1r- cv W9 iCo76 cA <i ¢2 <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 [Wending Machines Number of Units <br />lid Retail Market—Square footage 0S0 ❑ with Meat Market only ❑ Multiple Departments*repackaged 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 />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ----------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <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 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 />❑ Hotel/Motel —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 ❑ UK; Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility -6- ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -.-----Maximum number of birds _ <br />❑ Spa <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />❑ Pemtanent Cosmetics (4122) <br />❑ Pumper VehicleRegistration # 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 ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost 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 Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON <br />Ot',/fliv IVICJLS'9rsJ <br />Day PhS/C'-Z`tCY G67.Y <br />Night Ph JM <br />PROGRAM ELEMENT <br />INSPECTOR# <br />FEE <br />PERMIT VALID <br />❑ Surcharge FEE <br />t0 <br />❑ Other FEE _ <br />❑ Food Handier <br />❑ Check # AMOUNT PAID Date <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE <br />INVOICE # <br />Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15!07 <br />