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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM U New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID LA (a) 1 oil"5 Program Record ID FROOM07 302' / Facility Address `tS Z -C 5 hYv' `'1 `1 C1 S1 b4 tz-V-i C� (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation []Vending Machines —Number of Units ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -----Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit --Make Vehicle Type Registration # License # ❑ Temporary Food Facility -----Dates of operation from to ❑ Special Event -- Dates of operation from to _ Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle / Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ------------------❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ,.,❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste IT/ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST I��t Dl?0 9 dl i' � UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use LISTA and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee HousinpiLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PooUSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm ---Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (412 1) F-1 Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets -------Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash 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 PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --- El 2 - 10 ------ ❑ 11 - 60 ------ 11 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT x7, !1 ii FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR # D q('1 PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 M tell Record Pink 10/6/2003 1