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{ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro am at Existing Facility tg ,ew EH Program and New Facility <br /> Facilit•ID Program Record ID PAO 65L g q (e <br /> Facility Address VV- 1 c 71' s n 7.6 <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 /> 11Temporary Food Facility----Dates of operation from to 11 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) i <br /> ❑Hazardous Waste Generator- Tons Generated Per Year ❑Recycle[Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221&) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit By Rule Fixed Unit 17 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 CONTRO43000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site 11UIC Site <br /> 11Abandoned HW Site 13non-NPIdSEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pgol ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm—Ma ximum,number of birds ��n �7 <br /> T TTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) FED <br /> Tattooing(4121) El Body Piercing(4120) ❑Permanent Cosu> i�,(4122) <br /> LIQUID WASTE PROGRAM(4200) �HKK 1 2 2010 <br /> ❑ Pumper Vehicle-Registration# License# Capacity El!(11j <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets Number of U � <br /> SOLID WASTE PROGRAM(4400) �R,IMES H <br /> ❑Landfill ❑Transfer Station ❑Ag I 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/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) t.z <br /> ❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY NDIOR PROGRAM <br /> CONTACT PERSON � t MoD Day Ph 3 `N Ye Night Ph <br /> PROGRAM ELEMEIN'T 4B 4C2-1 FEE "t:T ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 34tz3 PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT <br /> �r P/A�I3D Date INVOICE# <br /> 8!1 J <br /> 0 Cash REVIEWED BY l5(�1 O 2-4 ACCOUNTING OFFICE Date <br />