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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM JAN Q 3 ZO <br /> ❑New EH Pro am at Existing Facility ❑New EH Prom and New Facility SAN JOAQ <br /> Facility IDA ' Program Record ID ) 3 HFA0HGNMFLOUNry <br /> �EPARTTAI T <br /> Facility Address 9 80D v b aAa�J �I uTT / T 7"� MFN <br /> (Please fleck the appropriate description and specify sim number or units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs❑ 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 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 from - to ❑ Ice Plant <br /> ❑Special Event -Dates of operation from to ❑Produce Stand <br /> - DAIRY PROGRAM(2000) <br /> - ❑ Grade A Dairy ❑ Grade B Dairy ❑ Wilk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> MIIaOUS WASTE PROGRAM(2200) <br /> zardous Waste Generator Tons Generated Per Year S TtY�) ❑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 <br /> .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA 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 Eml*ree Itousiap/Labor Camp Appliea&x 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 IIW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑\Vater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) - <br /> Number of Pools/Spas at Facility ❑P9ol ❑ 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(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - <br /> ❑ PumperVelicle-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/CanneryWaste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑CIALanditll Site <br /> ❑Refuse Vehicles-Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch 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-0 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PNS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACTPERSON // __ Day Ph Night Ph <br /> PROGRAM ELEMENT `7�iZ t7 FEE 3'! ❑ Surcharge FEE '. ❑ Other FEE <br /> INSPECTOR# PERMIT VALID . \,1 :3 � I to \Z Is ❑Food Handler <br /> T <br /> Whcok# '5 AMOUNT PAID aJ . 60 Date 3 n & INVOICE# <br /> 11 Cash REVIEWED-BY ACCOUNTING OFFICE Date j-� <br />