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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ew EH Program and New Facility <br /> Facility ID O L� ,lc,1 Z: Pro ram Record ID <br /> Facility Address c:"J S 7_0 <br /> (Please Check the appropriate description and specify ElLe,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> � Restaurant: Seating Capacity (,Z(_S'v Square Footage Food Handlers Course required:.. YEs�No ❑ <br /> 0<1commissary ❑ 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 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 /> ❑ 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 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 UST A 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 Employee llousim-Kabor 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 IiW 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 Pool/Spa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑Ke 1 j.M <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ��T <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent C 412Q <br /> LIQUID WASTE PROGRAM(4200) /y IN✓pq # <br /> ❑ Pumper Vehicle—Registration# License# Capacity �l❑ Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of UnrtP , �FCOti <br /> SOLID WASTE PROGRAM(4400) FNr <br /> ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch 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--[] 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Plf'SEFID46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON q{ Day Ph Night Ph <br /> PROGRAM ELEMENT FEE R oU CA) ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 1 /W� ERMIT VALID ` 124�0 1 to 41 '-���� ❑Food Handler p <br /> ❑ Check# V I Sti AMOUNT PAID 4.2- 0. 0 D Date `f Y'] O INVOICE'r# 1�,q o`� <br /> 0 CashA o4510PREVIEWED BY 'j Z ACCOUNTING OFFICE ( Date <br />