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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEyNT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH progM at Existing Facility ❑New EH Program and New Facility <br /> Facili IDs17 1 <br /> ? Pro ram Record ID (w" 0S <br /> Facility Address ''� D60 '�'t`f — <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No❑ <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Machines-Number of Units <br /> 11 Retail Market----Square footage 13 with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> El 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 /> El Temporary Food Facility----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event--Dates of operation from to 11 Produce Stand <br /> DAIRY PROGRAM(2000) , <br /> ❑ Milk Dispenser---Number of Containers in Multi Head Unit <br /> ❑ Grade A Dairy ❑ Grade B Dairy <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/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 /> k <br /> BOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> NDERGROUND STORAGE TANK(LIST)PROGRAM(2300) Use USIA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housine/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB 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 11 Kennel <br /> m <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--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 1111 Landfill El Transfer Station Ag 1 Cannery Waste Site EJSludgelAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd---Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility ---❑ 2- 10------011 -60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWSEHD 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 Z 3�[a FEE — ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# — PEST VALID to ❑ Food Handler_ <br /> ❑ Check# . A,ri0l3NT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 7 -1 10 <br /> M rf-ile Record Pink <br /> 48-02-034 <br /> 10/612003 <br />