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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT VICE" MASTERFILE RECORDINFORMATIOE FORM ❑New EH Program at Existing Facility New EH Program and New Facility APR 2.4201 Facility ID Program Record IDENVIRONMENT HEALTH Facility Address Z�( PERMIT/SERVICES (Please Check the appropriate description and specify s,_,e. number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation Ovending Machines Number of Units ❑Retail Market—Square footage ❑with Meat Market only O Multiple Departments ❑Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# O Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# O Temporary Food Facility----.Dates of operation from = to O Ice Plant ❑ Special Event —Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) O Grade A Dairy ❑Grade B Dairy O Milk Dispenser Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) O Hazardous Waste Generator--- Tons Generated Per Year _ O Recycle/Exempt System(2299) O CRT Offsite Handlers(2218) D Silver Only(2222) O Appliance Recyolers(2217) Tiered Permitting Facility O Conditionally Authorized(CA) ®Conditionally Exempt(CE) ❑Permit By Rule Fixed Unit O Permit-By-Rule Household Hazardous Waste ❑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 EoushtKabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROI.(3000) 13 Environmental Assessment 17 UST-CAP Site O Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site ❑Abandoned Hsi'Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out of Service Pool(Spa ®Natural Bathing Area VECTOR.CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO,BODY I NG,PERMANENT COSMETIC PROGRAM(4100) It l t O 9 Tattooing(4121) ❑Body Piercing(4120) O Permanent Cosmetics(4122) LIQUID WA GRAM(4200) ❑Pumper Vehicle—Registration# License# Capacity Vehicle-ft ❑Pumper Yard O Package Treatment Plant- ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) O Landfill ❑Transfer Station ❑Ag I Cannery Waste Site ❑Sludge/Ash Site O Waste Tire Facility O Compost Facility ❑Process/RecycIe Facility ❑CIA-Landfill Site ❑Refuse Vehicles—Number of Units ❑Dumpslers>20 cu yd----Number of Units O Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care . ❑Acute Care O Skilled'Nursing ❑Large Generator ® Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility—Z]2-10—1111-60------❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON v.\h .1 Day Ph�-0`1 -'5 GG: 1 (6 Night Ph PROGRA ENT FEE aC .� ❑ Surcha FEE'• ❑ Other FEE INSPECTOR## UZI- PERMIT VALID / to U ❑Food Handler ❑ Check# AMOUNT PAID Date INVOICE#®�J ❑ Cash REviEWEDBy ACCOUNTING OFFICE Datef O[ �,. cterfle Record Pink