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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Program and New Facility RECe m'E'D UN `' 9 2010 EN,l Facility ID � Program Record ID � /�?� Ui�lFrylT � r Facility Address SS' sou e �i 4' S Z'`F i/Op `' %jces l #� t�'� i �� r,1., (Please Check the appropriate description and specify size, number of units and pertineaf information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs ❑ No ❑ ❑ Commissary ❑ Drystorage only D with Food Preparation ❑ Vending Maehiues Number of Units ❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit -Make Vehicle Type Registration # License # ❑ Temporary Food Facility —Dates of operation from to ❑ Special Event -Dates of operation from to _ Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle / Exempt System (2299) ❑ CRT Offsite Handlers (2219) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous `'haste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel Number of Units .❑ Jail or Exempt Institution Number of Units Employee housing (2700) Use Employee Housinp/Labor Camp Application Form SITE MITIGATION (2900) - - UNDERGROUND INJECTION CONTROL(3000) .❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site, 13NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site 13non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site 1I Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility . ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds _ T 00 BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) Tattooing (4121) ❑Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel ❑ Permanent Cosmetics (4122) ❑ Pumper Vehicle -Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plaat• ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA -Landfill Site ❑ Refuse Vehicles -Number of Units ❑ Dumpsfers > 20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator Q Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--[] 2 -10 ❑ 11- 60 —❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWSEHD46-02-003 Blae Application Form EMERGENCY NOTIFICATION FOR THis FACILITY ANDIOR PROGRAM CONTACT PERSON L t E /L Q C..A �i -ADay Ph I - 5& Night Ph PROGRAM ELEMENT 41V FEE ' _� ❑ Surcharge FEE'"- ❑ Other FEE INSPECTOR# '?T7 2, PERMITVALID to 11 Food Ha LLL ." ❑ Check # AMOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY G-0 0 3-2-- ACCOUNTING OFFICE Date