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SAN JOAQUIN COUNTY ENVIROMIENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existin .Fac'►tity []New EH Program and New Facility <br /> Facility H) Z9 Pro ram Record ID <br /> Facility Address [144� LLA- �- <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 1:1 Restaurant: Seating Capacity Square Footage Food Handlers Course required:.. Yes El No <br /> ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation 11 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 /> ❑Temporary Food'Facility----<Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM,(ZOW) <br /> ❑Grade A Dairy 13.Grade B Dairy ❑Kill,Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) l <br /> ❑ Hazardous Waste Generator--------Tons Generated Per Year ❑Recycle I 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 tomes <br /> HOUSING PROGRAM(2400) <br /> ❑HoteLlMotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee HousinglL'abor Carrera Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) <br /> ❑Environmeatal Assessment ❑UST-CAP Site ❑Local HSV Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned ITW Site ❑non-NPLISEP Cleanup Site ❑RNVQCB 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) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—RegiShation# License# Capacity Vehicle•# <br /> ❑ Pumper Yard ❑Package Treatment Plaut• ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ask Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA•LandfiU Site <br /> ❑Refuse Vehicles Number of Units L7 Dumpsters>20 cu yd Number of Units ❑Farnulkanct:.Cleanup Ate <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled'Nursing ❑Large Generator Q Small Generator U I k"dted Ha_ er <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[]2-10 ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWSEMD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON w+r�+^ � "_P � � Day Ph-z.o et 1 t/r' 17 7J3!_ Night Ph <br /> PROGRAM ELEMEN•111/0 FEE ❑Surcharge FEE". ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWEDBY ACCOUNTING OFF ICE Date <br /> Masterfile Record Pink <br />