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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIti1ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ew EH Proograni and New Facility <br /> Facility TD o L) s7 Pro ram Record ID pc <br /> Facility Address ��� Ft3u Yh 74 1 01)n <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes 11 No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units <br /> El 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 /> 11 Temporary Food Facility—Dates of operation from to El ice Plant <br /> [I Special Event —Dates of operation from to Produce Stand <br /> DAIRY PROGRAM(2000) <br /> 11 Mill, of Containers in Multi Bead Unit <br /> El Grade A Dairy El Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IiAZA.RDOUS WASTE PROGRAM(2200) t <br /> ❑hazardous Waste Generator-- Tori Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ElCRT Offsite Handlers(2218) [1Silver Only(2222) ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Pcm-iit-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 /> ❑ Hotcniotel Number of Units ❑Jail or Exempt Institution--Number of Units <br /> Employee Ifousing(2700)Use FrrrplopeeKousin j7/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAronmental Assessment ❑UST-CAF Site ❑Local I11V Cleanup Site• 11NPUSEP Cleanup Site ElUIC Site <br /> ❑ Abandoned IIW Site 11 non-NPL/SEP Cleanup Site ElR\VQCB Cleanup Site ❑!Vater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) 11 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 /> El Landfill El Transfer Station El Ag I Cannery\`'aste Site ❑ Sludge/Ash Site <br /> v4Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Landfill Site <br /> ❑ I'efuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ FarmTRaach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use FWS lith 4642-003 Rhic Applica(ion Form <br /> EMERGENCY NOTIFICATION FOR Tills FACILITY ANDIOR PROGRAM <br /> CONTACTPERSON Day Ph Night Ph <br /> PROGRADt EL^EN'I-ENTq Im FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# d 7�C}- PE"III VALID . to ❑ Food handler <br /> ❑ Check# AiNIOUNT PAID Date I14VOICF It _ <br /> ❑ Cash REVIEWEDBY 1£ 1D 1p AccoUNTING OFFICE Date <br />