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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH ProoM and New Facility <br /> Facility ID D Program Record ID <br /> Facility Address l I D 11 5 U e l- )Ke e, { -n <br /> (Please beck 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: 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 /> -i ❑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 ❑Milk Dispenser—Number of Containers in Multi-Head Unit - <br /> CUPA ,State Facility Surcharge(2399) _ <br /> HAZARDOUS WASTE PROGRAM(2200) - t <br /> (Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(221&) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pemrit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(US1)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) - <br /> ❑Hoteimotei—Number of units ❑Jail or Exempt Institution—Number of Units <br /> Employee Rousing(2700)Use FnrotoPee Heusine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑14W HW Cleanup Site ❑NPIJSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediatiou Site ' <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑ Spa ❑Out of Service PooBSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) - <br /> ❑Poultry Farm—Maximum number of birds _ ❑Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRANt(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <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 I 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 ❑FarmfRanch Cleanup Site .. <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care . ❑Acute Care ❑SkilledNursing ❑Large Generator ❑ 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 PII SF11D 4&02.003 Blue Appfication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELF.ME1NT a2OOrO FEE '00'049 );1 Surcharge FEE o94 — ❑ Other FEE <br /> INSPECTOR# 5_7S3 PERMITVALID to ❑Food Handler <br /> ❑Cheek# AMOUNT PAID D — Date INVOICE# 159 W 1`1 <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE �ei Date -a'/o <br />