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r <br /> `SAN JOAQUIN COUNTY ENVIRONNI.ENTAL HEALTIi DEPARTnIENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility []New EH Program and New Facility <br /> Facilif ID ?j �$ Pro ram RecordID 't3 <br /> Facility Address t5 (aTr, L. a� , 151A& <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 11Vending Machines—Number of Units <br /> ElRetail Market—Square footage ❑with Meat Market only, ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ElMobile 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(20W) <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)' t <br /> ❑Hazardous Waste Generator..— Tons Generated Per Year ❑Recycle/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 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 /> ❑ Iiotentotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Ifoasinglf-aborCamp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑Local UW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> 11 Abandoned IINY Site ❑Ron-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑`Fater Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P901 ❑ Spa ❑ Out of Service Pool/Spa ❑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(4121) ❑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 ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled'Nursing Large Generator Q Small Generator 11 Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Comman torage Facility---❑ 2-10 ❑ i l-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePl1'SEHD 46-02-003 ElucApplication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON _ Day Ph Night Ph <br /> PROGFL41 ELEMENT_LS�'D _ FEE �.7.* ❑ Surcharge FEE`- ❑ Other FEE _ <br /> INSPECTOR# —_ PERMITVALID_ to Food Handler_q <br /> ❑ Chcck 9 AAIOUI`rr RbAl) &%�L.ab__ Date INVOICE# <br /> Cash REVIEWED BY 96 'Sid <br /> ACCOUNI114G OFFICE _ __ � Date <br />