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El Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />1:1 Dumpsters > __ ,n Cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID F40027,5 / <br />Facility Address / <br /> <br />Program Record/ID 7RDS-ZiL2- <br />6 <br /> <br />(Please check check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />CI Commissary 0 Dry storage only <br />Retail Market----Square footage <br /> <br />04/1q-bile Food Vehicle --Make <br /> <br />Registration # <br />Mobile Food Prep Unit Make <br /> <br />Registration # 7 > <br />Temporary Food Facility --Dates of operation from <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator Tons Generated Per Year <br />CRT Offsite Handlers (2218) CI Silver Only (2222) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) <br />0 Permit-By-Rule Fixed Unit <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 CI Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site ID Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator El Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 <br /> <br />0 > 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 2- 0 Surch ge F 0 Other FEE <br />INSPECTOR # PERMIT VALID 2- 202 to 0 Food Handler <br />CI Check* V/ AMOUNT PAID Date .2.-Er INvoicE# 2777S7) <br />Cash REVIEWED BY ACCOUNTING OFFICrLit ) Date .2/q/-2.3 <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation :Wending Machines Number of Units <br />0 with Meat Market only CI Multiple Departments0 Prepackagd Goods Only <br />Vehicle Type ri Color IA) I'll <br />License # Sticker # /I/ cie)o <br /> Vehicle Type Color <br />>)--//4 Sticker # <br />to <br />License # cis 0 <br /> 1 <br />0 Ice Plant <br />0 Produce Stand <br />CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />Recycle/Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />Conditionally Exempt (CE) <br />Permit-By-Rule Household Hazardous Waste <br />0 Out of Service Pool/Spa 0 NatPAYMPtIga <br />RECEIVED <br />CI Kennel <br />FEB 0? 2023 <br />0 Permanent Cosmetics (41221 <br />SAN JOAQUIN cOUNTY <br />ENVIRONMENTAL <br />Capacity ilita414 DEPARTMENT <br />CI Chemical Toilets —Number of Units <br />MASTERFILE RECORD INFORMATION PINK 48-02-034 <br />11/15/07