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• <br />I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proqram at Existing Facility ❑New EH Program and New Facility <br />I Facility ID !Jf% [ `1 / Prol <br />< Facility Address 73062_.rz)5-1 S- - <br />(Please check the appropriate description and specify size, <br />FOOD PROGRAM (1600) <br />Record ID <br />-Z::�4 0 <br />and pertinent information.) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle --Make Vehicle Type _ <br />Registration # License # <br />❑ Mobile Food Prep Unit Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from _ <br />❑ Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />License # <br />"N• <br />7.) <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments❑ Prepackaged Goods Only <br />'N• <br />_ Color <br />Sticker # <br />Vehicle Type _ <br />Sticker # <br />Color <br />_ ❑ Ice Plant <br />❑ Produce Stand <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA ❑ 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 Cama Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ 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)?7k05a$,5$?' aBody Piercing (4120)PROPermanent Cosmetics (4122)?&6&AM <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 (# of units) ❑ Dumpsters > 20 cu yd I# 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 />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # PERMIT VALID t0 ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07 <br />