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SAN.IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New Ell Program at Existing Facility ❑Ncw Ell Program and New Facility <br /> Facilit•ID 7 ` Pro ram Record o� <br /> Facility Addl es's J/� ,3 .S/,?h/4-1111✓F <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 13 Restaurant: Seating Capacity Square Footage Food Handlers Ci. ourse required: YFs 11 No El <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units. <br /> ❑ Retail Market---Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only <br /> Vehicle❑ Mobile Food Vehicle--MakeeVehiT)rpe Color <br /> Sticker# <br /> Registration# License# <br /> ❑Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility-----Dates o_f operation from to 11 Ice Plaut ` <br /> [3 Special Event --Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Mill:Dispenser Number of Containers in Multi-Bead Unit <br /> ti-CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PICOGRAM(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 P t-By-Rule Household Hazardous Waste <br /> �J ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> 1 .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B <br /> HOUSING PROGRAM(2400) <br /> ❑HotellMotel Number of Units r ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use F.mployee Housing/Labor Camp ApPItLea ern,Forrrr <br /> SITE MITIGATION(2900) UNDERGROUND IN.IECTION CONTROL(30W) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLJSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPLGEP Cleanup Site ❑RNVQCB Cleanup Site ❑'%Vater Quality Remediation Site <br /> RECREATIONAL HE=ALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑P4ol ❑Spa ❑Out of Service Pooltspa Q Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> [3Poultry Farm Maximum number of birds El Kennel <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 It Capacity Vehicle# <br /> ❑pumper Yard ❑Package Treatment Plaut ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑Ag/Cannery\Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA,Landflll Site <br /> ❑Refuse Vehicles--Number of Units ❑Dumpsfers>20 cu yd----Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> E3 Primary Care 11 Acute Care ❑ Sl:illed'Nursing ❑Large Generator 0 Small Generator Q Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EHD 46-02-003 Blue ApplWfian Form <br /> Emr=PmENGY NOTIFICATION FOR TH1s FACILITY ANWOR PROGRAM <br /> CONTACT PERSON A Day Ph Night Ph <br /> PROGRAM ELEMENT 2 a FEE ❑ Surcharge FEE ❑ Other FEE <br /> IrisPBCTOR# 2 1P RMIT VALID . to 13Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash RFvjrwEDBY ACCOUNTING OFFICE JC­rDate pG / <br /> M ?v ,Ro-rnrA Pink <br />