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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORM <br /> New EH Program at Existing Facility ❑New Ell Program and Ne-v Facility <br /> Facility 1D Program Record ID Q <br /> Facility Address ?may 1:t_ L)e_-& I-A-c _ :&t� <br /> (Please.heck the appropriate description and specify s,jZ number of units and p rtiinent 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 /> ❑ Retail Market----Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ 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 /> ❑ Temporary Food Facility--••Dates of operation froth to ❑ ice Plant <br /> ❑Special Even( --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator.' Tons Generated Per Year ❑Recycle f 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 /> ABOVEGROUND STORAGE TANK FACILITY(AST)(a3- @ Number of AST tai Z04at 1 0`Oda <br /> ffffff UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST.t and B towns <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units ❑Jailor Exempt Institution Number of Units <br /> Employee Iiousiag(2700)Use EmployeeHousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑non-NPLISEP Cleanup Site C7 RlVQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ©Pumper Vehicle--Registration# License# Capacity Vehicle-# <br /> ❑ Pumper Yard 0 Package Treatment Plant• ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag f Cannery Waste Site ❑ SludgelAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA;Laudfll 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 Cart ❑ Skilfed'Nurs'Ing ❑Large Generator 0 Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHSGHD46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMEIY I �j I-- - _ FEE © Surcharge FEE '- ❑ Other FEE <br /> INSPECTOR# �{{Q � PERMIT VALID . to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REViEWEbBY ACCOUNTING OFFICE Date e Il <br />