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SAN JOAQUTIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORBI <br /> New FH Program at Existing Facility []New EH Program and New Facility <br /> Facility ID � �,� Pro ram Record ID �.��� <br /> Facility Address C f(A,_ <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 Mark=et----Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> 11Mobile 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 El Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy D Milk Dispenser—Number of Containers is Multi-Head Unit <br /> 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(2219) ❑ Silver Only(2222) _ ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fisted 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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑IloteUMotel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Housin lLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned 11W Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Qualify Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. 111'001 ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> 'Cl Poultry Farm Maximum number of birds ❑Kennel <br /> `TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pamper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle 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 /> ❑ PrimaryCare ' ❑Acute Care ,Skilled Nursing ❑Large Generator Q Small Generator ❑Limited hauler <br /> ❑ 'Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ fl-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PJVSEHD 46-02-003 BlueApplicafion Form <br /> EMERGENCY NOTIFICATION FOR TEAS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGFL4RtELEr,1ENT urJ.214 FEE 0S ❑ SurlchargeFEE ❑ Other FEE <br /> INSPECTOR# d.(e PERMITVALID ]�_ to { ��j�'�,) ❑ FoodHandier <br /> _Q <br /> 11 check g Aiiiowr P e Ii) !L L ob Date INVOICE#-7 1 1-4 `- <br /> 0 Cash P EviE ED IIP ?j Al COUNTING GFFICE T Date 3 ` _--- — <br />