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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> tkNew EH Program at Existing Facility ❑New EH Pro&M and New Facility <br /> FacilityH) Fft 0 00 Pro ram Record ID PR V,1��222LL <br /> Facility Address O A) P f3' \AA 7—nxC=P <br /> (Please Check the appropriate description and specify j!je,numbe 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 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 /> TS'ale Facility Surcharge(2399)AZARDOUS WASTE PROGRAM(2200) t <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 Facality ❑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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Rousing(2700)Use Fmplovee Housine/Labor Camp Application 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 HW Site ❑non-NPLSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Ppol ❑ Spa 13 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(4 121) ❑ 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/Cannery Waste Site ❑Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIALand011 Site <br /> ❑Refuse Vehicles-Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑ Farou Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care - ❑Acute Care ❑ Skilled Nursing ❑Large Generator 13 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 PHS EHD 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSONssem�..,. Day Ph Night Ph <br /> &R <br /> PROGRAMELEMENT &R-O") FEE ❑ Surcharge FEE El Other FEE <br /> INSPECTOR# PERMIT VALID . /-/-B7 to /,7-4t-07 ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REvIEWEDBY LT 6 &'67 ACCOUNiINGOFFICE Date <br />