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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New Ell Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID D D ( ram Record ID #L& <br />Facility Address A— v-2 <br />(Please Check the appropriate description and specify sizenumber of units and pertinent information.) <br />PAYMENT <br />RECEIVED <br />5EP 2 5 2007 <br />SAS�V l� <br />ENVI 'fDD <br />HEALTSEPANT <br />2 �iE2o0% <br />ENVIRONMEINT HEALTH <br />PERMIT/SERVICES <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity,� Square Footage Food Handlers Course required: YES11No El <br />❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending Machines —Number of Units <br />❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility—Dates of operation <br />❑ Special Event —Dates of operation from <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />from to <br />to -- <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Mill: Dispenser ---Number of Containers in Multi-Ilead Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />IiAZARDOUS WASTE PROGRAM (2200) i <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 U,ST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ IIotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee housing (2700) Use Employee Ifousinz/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment 11UST-CAPSite ❑ Local IPV Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned IIW Site ❑ non-NPIJSEP Cleanup Site ❑ R\WQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farrar Maximum number of birds ❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity Vehicle# <br />❑ Pumper Yard 11Package Treatment Plant 11 <br />chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd --Number of Units ❑ FarnvRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Ilauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility -13 2 - 10 ❑ 11 - 60 ----❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PH'S E/[D 46-02-003 Blue Application Form <br />EMERGENCT NOTIFICATION FOR TIAIS FACILITY ANDIOR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT -' FEE ❑ SurchaarrgeFEE I-] Other <br />- �yOther FE <br />INSPECTOR # PERMIT VALID Q[a-7 to —�� 3`0 � � p ❑ Food handler <br />�Clicck# iw::::_AMOUNT PAID � Date y r7� INVOICE # <br />Cash REVIEWED BY ACCOUNTING OFFICE _! - Date �j,l 7 <br />