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SAN J"OAQUIN COUNTY ENVIRONN1,ENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFOrOIATION FORM <br /> ❑New Ell Program at Existing Facility ❑New EH P�r}ogrram and/New Facility <br /> FacilityID L) , 3' Pro ram Record ID 5 <br /> Facility Address Ao 5 r E- <br /> (Please Check the appropriate description and specify ELLze number of units and (pertinent information.) <br /> FOOD I°ItOGRAhS(1604) <br /> VI Restaurant: Seating Capacity Square Footage hood Handlers Course required:. YEs El No ❑ <br /> ❑ CommissaryElDry storage only ❑with Food Preparation ❑Fending Machlnes—Number of Units <br /> ElRetail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackagcd Goods Only <br /> El MobileMobilFood'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(2040) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Mill:Dispeaser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> I-IAZARDOUS\VASTE PROGRAM(2200)' i <br /> ❑Hazardous Waste Generator..— Tons Gonerated Per Year D Recycle f Exempt System(2299) <br /> site Handlers 2218 ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> ® CRT Off ( ) Y <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exearpt(CE) <br /> CI Permit-lay-Rule Fined 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 USIA and R Loans <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlotel Number of Units -❑Jail or Exempt Institution Number of Units <br /> tmployee Iiousirag(2700)Use Fmplo yee�ffausira>=/Labor Vamp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND 1NJECTION CONTROL(31100) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑Local II\V Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned 11W Site ® non-NPIJSEP Cleanup Site ❑RNVQCB Cleanup Site ❑\rater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service PoolfSpa ❑Natural Bathiag Area <br /> VECTOR CONTROL PROGRAM(4004) <br /> ElPoultry Farms 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(4204) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle <br /> El Pumper Yard ® Package Tre-atmeat Plaut ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill CJ Transfer Station El Ag/Cannery\Paste Site ® Sludge/Asla Site <br /> WWaste Tire Facility ❑ Compost Facility ❑ Process[Recycle Facility ❑ CIA-Laadfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled'Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfcr Station ❑ Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Usef 1VSEKD fG-02-003 B1r4re Applica(iori Form <br /> EMERGENCY NOTIFICATION FORTHts FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph — <br /> PROG13-01I+LEmENT ! <br /> FE_ ❑ Surcb/argeFEE ElOther FEE <br /> 1NsrFCT0R# — PERMIT VALID tob��(7� ❑ Food Handler__ <br /> Cl Check f. AmoulVT P h,1u Date �IINOICE It <br /> !ash RI:VIEWE..D BY -- AI CO(JClTIN!i OFFICE r DdtG -- <br /> ____—�_—_— --� __ <br />