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A <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Mew EH Pro ram at Existing Facility ❑New EH Prom and New Facility <br />Facility ID / O Program Record ID P20c!53120 <br />Facility Address E. JZinC. Coir St. <br />(Please Check the appropriate description and specify size, number of units and pertinent information) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs ❑ NO ❑ <br />❑ Commissary ❑ Drystorage 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 <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />Vehicle Type <br />Color <br />License # <br />Sticker # <br />Vehicle Type <br />Color <br />I i-. <br />Cfir4rr if <br />❑ Temporary Food Facility—Dates of operation from <br />❑ Special Event —Dates of operation from to <br />_ ❑ Ice Plant <br />❑ 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) - . y <br />❑ Hazardous Waste Generator. Tons Generated Per Yearf3 Recycle -f Exem t System 22 ) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ppliance Recyclers <br />Tiered Permitting Facility ❑ Conditionally Authorized ( nditio� yy Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />. UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A 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 Finployee Ifousine/Labor 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 11 UTC Site <br />13Abandoned HW Site 13anup <br />non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediatiou 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 _ ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIOUID WASTE PROGRAM (4200) <br />❑ Permanent Cosmetics (4122) <br />❑ Pumper Vehicle—Registration # License # Capacity Vehicle# <br />❑ Pumper Yard . ❑ Package Treatment Plant. ❑ 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 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 — 1111 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EMD46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br />CONTACTPERSON <br />PROGRAM ELEMENT 6? I FEE_ <br />INSPECTOR#/!Vs2� PERMITVALID <br />Day Ph <br />Night Ph <br />❑ Surcharge FEE . ❑ Other FEE <br />to <br />❑ Check# MM <br />A�OpUNT PAID Date <br />11Cash REVIEwEDBy3r Ghlj_ ACCO[MnNG OFFICE <br />❑ Food handler <br />INVOICE # <br />Date e <br />