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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Pro at E^listing Facility ❑New EH Pro and New Facility <br />Facilitv ID An 1 lJ Program Record ID RQS1� (ol <br />Facility Address S L1 11 J t- I I p" T u <br />(Please Check the appropriate description and specify size, number of units and pert; <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating CapacitySquare Footage <br />❑ Commissary ❑ Drystorage only ❑ with Food Preparation <br />fact E3 with Meat Market only <br />❑ Retail Market ----Square oo age <br />Vehicle Ty <br />❑ Mobile Food Vehicle ---Make <br />Registration# <br />License; <br />❑ Mobile Food Prep Unit --Make <br />Vehicle Ty <br />Registration # <br />License <br />❑ Temporary Food Facility ---Dates of operation from <br />❑ Special Event -- Dates of operation from <br />Food Handlers Course required: Yes ❑ No ❑ <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker# <br />Color <br />Sticker # <br />to <br />_ ❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) i <br />[1 Milk Dispenser ---Number of Containers in Multi -Head Unit <br />❑ Grade A Dairy ❑ Grade B Dairy <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) c NS <br />Generated Per Year p Recycle/ / Exem t System (2299) <br />Hazardous Waste Generator --------Tons <br />' <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 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B (arras <br />HOUSING PROGRAM (2400) <br />❑Jail or Exempt Institution --Number of Units <br />❑ HotcVMotel ------Number of Units <br />Employee Housing (2700) Use Employee Housine/Labor Cama Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment [I UST -CAP Site 11 Local HW Cleanup Site LJNPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned FiW Site <br />❑ 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) ❑ Kennel <br />❑ Poultry Farm—Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑permanent Cosmetics (4122) <br />❑ Tattooing (412 1) El Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />R ' tration # <br />License # Capacity Vehicle # <br />Li Pumper Vehicle-- egts i <br />❑ Package Treatment Plant ❑ Chemical Toilets—Number <br />of Units <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />❑ Ag /Cannery Waste line <br />❑ Sludge/Ash a/Ash Site <br />g <br />❑ Landfill ❑ Transfer Station <br />❑ Compost Facility ❑ Process/Recycle Facility <br />❑CIA Landfill Site <br />❑ Waste Tire Facility <br />❑ Dumpsters > 20 cu yd --Number of Units <br />❑ Farm/Ranch Cleanup Site <br />❑ Refuse Vehicles --Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small <br />Generator ❑ Limited Hauler <br />❑ Primary Care <br />❑ Common Storage Facility ---❑ 2 - 10 -- <br />❑ 11 - 60 -----❑ > 60 generators <br />❑ Transfer Station ❑ Veterinary Clinic <br />WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-01-003 Blue Application Form <br />PUBLIC <br />CONTACT PERSON <br />I M AA a r y l f1 Day Ph — 1011 (Ivtgnr rn <br />PROGRAM ELEMENT Z7 2y FEE 6D . � ❑ Surcharg FEE ❑ Other FEE <br />O to f I Dy ❑ Food Handler. <br />INSPECTOR# t5 31 -7 PERMIT VALID _ ��Q� Date INVOICE# yI <br />❑ Check# AMOUNT PAID td'1. / / <br />❑Cash REVIEWED HY <br />ACCOUNTMG OFFICE <br />Masterfile Record Pude <br />4&02-034 _ <br />10/62003 <br />