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Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 CU yd (# of Units) <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />Square Footage <br />0 with Food Preparation <br />0 with Meat Market only <br /> Vehicle Type <br />C...(7-(f)-5 410MLicense # 6 <br />Make <br />Food Handlers Course required: YES 0 <br /> <br />I:Vending Machines Number of Units <br />0 Multiple Departmentsp Prepackagecilfzds <br />3;2, t) Color t <br />Cf4. I) Sticker # <br />Vehicle Type Color <br />Only <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />CI Hazardous Waste Generator <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />0 Produce Stand <br />0 11 - 60 0 > 60 generators <br />MERG NCY OTIFICATION FOR T F CILITY AND/OR PROGRAM <br />CONTACT PERSON I \._ I t iLf Night Ph 2_ 0 6 3 K <br /> (\ <br />PROGRAM ELEMENT -f7 P(iE 70-e 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # ill-r4/2., 7, ERMIT ALID to 0 Food Handler <br />El Check # AMOUNT PAID Date INvoicE# i i <br />Cash REVIEWED B - -----ACCOUNTING OFFICE ar6 Date ‘71/ /AS---- <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />P-New EH Program at Existing Facility <br />Facility ID r-7400167(„01--- Program Record ID <br />:New EH Program and New Facility <br />Facility Address / 7 C Pe Cl' <br /> <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />)t Mobile Food Vehicle --Make <br />0 Retail Market----Square footage <br />Registration # <br />Mobile Food Prep Unit <br />Registration # <br />License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant <br />Tons Generated Per Year 0 Recycle/Exempt System (2299) <br />CRT Offsite Handlers (2218) 0 Silver Only (2222) 0 Appliance Recyclers (2217) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 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 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site Cl UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07