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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility xNew EH Program and New Facility <br /> Facility ID Q3 Pro ram Record ID 53S733 <br /> Facility Address A- <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes[I No El <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Markel 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 /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑Ilazardous Waste Generator --- Tons Generated Per Year ❑ Recycle J Exempt System(2299) <br /> ❑CRT Offsite Ilandlers(2219) , ❑ Silver Only(2222) 1 ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility - ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Pernut-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ notenjotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee ffousitt TIT abor Camp Application Fomi <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ En`dronmental Assessment ❑UST-CAF Site ❑ Local IIW Cleanup Site• ❑ NPLISEP Cleanup Site ElUIC Site <br /> [IAbandoned IIIV Site ❑ non-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑Pool ❑ Spa ❑ Out of sen-ice Poollspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds El Kennel <br /> TATTOO 13ODY 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 ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag J Cannery Waste Site ❑ Sludge/Ash Site <br /> ,{Waste Tire Facility ❑ Compost Facility ❑ ProcessJRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care 11 Acute Care ❑ Skilled Nursing 11 Large Generator E) Small Generator ❑ Limited Iiaulcr <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—[] 2- 10 ❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Usc PMSG/fD 46-02-003 Mae Applica(ion Form <br /> EMERGENCY NOTIFICATION FOR T141s FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGI2AN1 ELFMENT 41TYQ_ FEE _ ❑ Surcharge FEE 11 Other FEE <br /> INSPECTOR# r c PEnflTVALID to ❑ Food Handler <br /> ❑ Check AMOUNT PAID Date INYOICF It _ <br /> ❑ Cash RE-yiEwEDBY ACCOUNTING OFFICE — Date <br />