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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New Ell Program at Existing Facility New Eli Program and New Facility Facility IDd(� S( Program Record ID l�5 Facility Address ?,42-:i E. rices—► ��tnclt-c,nn . C A 9 52()55 (Please Check the appropriate description and specify si' ze•number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Y"❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units ❑Retail Market----Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility----Dates of operation from to ❑ Ice Plant ❑ Special Event —Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ry ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) IIAZARDOUS\VASTE PROGRAM(2200) i ❑ hazardous Waste Generator-- Tons Generated Per Year ❑Recycle/Ezempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑Ilotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employ"Housing(2700)Use Employee IfousinglLabor Camp AppWatlon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAF Site ❑Local IIW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑Kennel TATTOO 13ODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ an ft ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site (]Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2- 10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)UsePf!'SFHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FORTIt15 FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGR,01ELEMENT g7`10 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMITVALID to ❑ Food Handler ❑ Check# A1IIOUNT PAID Date INVOICE# 0 Cash REVIEWED BY ACCOUNTING OFFICE Date V