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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPAR NT <br /> MASTERFH.E RECORD INFORMATION FORM <br /> New EH Pro -m at Existing Facility - ❑New EH Program and New Facili <br /> ty <br /> Facility ID l Lv3� Program Record ID — -7 �— <br /> Facility Address \15b�b 9-9 <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) _ <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: -YES No 13---- <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 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 r 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) <br /> El Hazardous Waste Generator------------Tons Generated Per Year �7..a� ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers (2218) [1Silver 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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ElJail or Exempt Institution—Number Qf_Units <br /> e H <br /> Employee Housing(2700) Use Emnloyeousin/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site - ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ R\\'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas 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(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity. Vehicle# <br /> ❑ Pumper Vehicle--Registration# License# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ <br /> ❑ Process/Recycle Facility CIA Landfill Site <br /> 1:1 Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> 11 Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units _ <br /> MEDICAL WASTE PROGRAM(4500) Limited <br /> 11Primary Care ❑ Acute Care ❑ Skilled Nursing El Large Generator [I Small Generator O 60 generatorsr <br /> El Transfer Station El Veterinary Clinic [I Common Storage Facility----[J2-10--El1 t-60 <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PR'S EHD 46-02-003 Blue Application Forni <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACTPERSON <br /> Day Ph Night Ph <br /> FEE ❑ Surcharge FEE ❑ Other FEE <br /> �— <br /> PROGRA31 ELEMENT ❑ Food Handler <br /> PERMIT VALID\ A to '� <br /> INSPECTOR# '� - INVOICE# <br /> ❑ Check# AMOUNTPAiD Date <br /> ACCOUNTING OFFICE Date <br /> ❑ Cash REVIEWED BY Masten a Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />