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A_SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existiav Facility ❑New EH Pro and New Facility Facility ID � Pro ram Record ID Facility Address l�Cl L (Please Check the appropriate description and specify EjM number of units and pertinent informafion.} FaaD PROGRAM(1600) ©Restaurant: Stating Capacity Square Footage Food Handlers Course required:. Yes❑ No 1:1 [JCommissary ❑ Dry storage only ❑with Food Preparation ❑'ending Mathiues—Number of Units 13 Retail Market—Square footage 13 with Meat Market only L] Multiple Departments [3Prepackaged Goods Only Vehicle Type Color ; ❑ Mobile Food Vehicle--Make Sticker# Registration# License# Color T Type❑Mobile Food Prep Unit—Make VehicleSticker# Registration# License.# to ❑ Ice Plant , 11 Temporary Food Facility:Dates o_f operation from ❑ produce Stand ❑ Special Event --Dates of operation from to DAIRY PROGRAM(2040 ❑ Mill:Dispenser Number of Containers in Mu1ti-Head Unit ❑Grade A Dairy ❑ Grade B Dairy CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) S [I Hazardous Waste Generator. ❑Rectle/Exempt Tons Generated Per Year Y P stem(Z299) ❑ CRT Offsite Handlers(2219) ❑Silver Only(2222) D Appliance Recyclers(2217) Tiered Permitting Facility-------�-----❑t;onditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit By-Rule Fixed Unit ❑P 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 o HOI1S114G PROGRAM(2400) ❑Hotel/Motel Number of Units ❑jail or Exempt Institution Number of Units Employee Housing(2700)Use Bmployee Housine/Labor Camp,4pplica6on Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL( 000 .13 Environmental.Assessment El UST-CAP Site ❑Local HW Cleanup Site. [I NPL/SEP Cleanup Site [3 UIC Site ❑Abandoned HW Site ❑uon-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area VECTOR.CONTROL PROGRAM(4000) F]poultry Farm Maximum number of birds 13 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PICOGRAM(4100) [3 Tattooing(412 1) 13 Body Piercing(4120) ❑ Permanent Cosmetics{4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# El Pumper Yard ❑Package Treatment Plant. ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑Ag I CanneryWaste Site ❑ SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles--Number of Units ❑Dumpsters>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site MEDICAL.WASTE PICOGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled'Nursing ❑Large Generator (3 Small Generator ❑Limited Hauier ©Transfer Station 0 Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10 ❑ 11-60---❑>60 generators PUBLIC WATER SYSTEM PICOGRAM(4600)Use PWS FffD46-02-403 BlueApelieation Form EMERGE=NCY NOTIFICATION FOR T141S FACILITY ANOIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAnt ELEMENTae 6 FEE ❑ Surcharge FEE ❑ Other FEE ImPECCOR#L4 f�rPERMITVALID . to ❑ Food Handier ❑ Check# AmOUNT PAID Date INVOICE# ❑ Cash REYIEWEIiBY ACCOUNTING OFFICE Date TIN1 - r �