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SAN JOAQUIN COUNTY ENVIIcONMENTAL HEALTH DEPARTMj_i,,4 - <br />MASTERFILE RECORD INFORMATION FORM <br />IX'New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facilit • IDL9-7 Program Record ID <br />Facility Address _?_`2__L 'G k-t`-Y�- <br />(Please Check the appropriate description and specify size• number of units and pertine t 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 <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility ----Dates of operation from <br />❑ Special Event —Dates of operation from <br />Vehicle Type <br />License # _ <br />Vehicle Type <br />License # <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <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 />COPA ❑ State Facility Surcharge (2399) <br />IIAZARDOUS WASTE PROGRAM (2200) 1 <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 />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST 137,D — <10000 <br />. UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Ilotet/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee housing (2700) Use Fmployee Housing/labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(30W) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local IIW Cleanup Site" ❑ NPL/SEP Cleanup Site ❑ UTC Site <br />❑ Abandoned IIW Site 13non-NPL/SEP Cleanup Site 11anup <br />RWQCB Cleanup Site ❑ Water Quality Remediation Site " <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 11 P901 13 spa ❑ Out of Service Poo]/Spa ❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds ❑Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4 120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />11 Pumper Vehicle—Registration # License # Capacity Vehicle <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill 11 Transfer Station 11 Ag / Cannery Waste Site ❑ Sludge/Ash 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 11 Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—[] 2 -10 ❑ 11- 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PHS EIfD46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR Tans, FACILITY AND/OR PROGRAM <br />."..,,.r—..., nonrf'1wt D -1v Ph Niplit Ph <br />PROGRAM ELEIl1ENT__Z�6 ( FEE <br />❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # D PERMIT VALID %Z I to <br />❑ Check # <br />❑ Cash <br />AMOUNT PAID <br />REVIEWED By A,'l /— <br />J <br />Date <br />ACCOUNTING OFFICE <br />❑ Food Handler <br />INVOICE 4"14 <br />Date <br />..Fr.v Rrrnr`i ➢inR <br />