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SAN JOAQUIN COUNTY EN . .ONMENTAL HEALTH DEPARTi vT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Proeram at Existing Facilit [:]New EH Pro ram and New Facility <br /> Facility ID Program Record ID P-0 S L l <br /> 07 <br /> Facility Address 5 I S I I��y �� 9 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> C3 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 11 N o El <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-----`,take " 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 /> C1Special Event --Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ <br /> ❑ Grade A Dairy ❑ Grade B Dairy Milk Dispenser --Number of Containers in Multi-I lead Unit <br /> COPA ❑ 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 USIA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> E:mplo}ee(lousing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment ElUST-CAPSite ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site El UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number oPooli'Spits at Faciliq 11Pool El Spa 11 Out of Service Pool/Spa El Natural Bathing Area <br /> f <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm -------klaNimum number of birds C3 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 13 Tattooing(412 1) El Body Piercing(4120) C1 Permanent Cosmetics(4 122) <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 /> ❑ Process/Ree cle Facility El CIA Landfill Site <br /> Waste"fire Facility El (:(),,,post Facility )' Y <br /> ❑ Dum P�- �,tort>20 cu d----Number of Units Elfarm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number of Units —_-_--_ Y <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care El Acute Care El Skilled Nursing El Large Generator El Small Generator 11 Limited Hauler <br /> 11 Transfer Station ❑ Veterinary Clinic [ICommon Storage Facility----112- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PFVS END 46-02-003 Blue Application For"? <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELF.NIENT t�7� l� FETE ❑ Surcharge FEE 11 Other FEE <br /> r" to 11 Food Handler <br /> ItvSrt.CTOIt# �tCt�'�' PLiRMff VALID <br /> ❑ Check N AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEN ED BS' 1h ACCOUNTING OFFICE �fi Date <br /> Masterfile Record Pink <br /> 48-02-(j',4 <br /> 10/6'2Uu3 <br />