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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID 9 %25A '7 ` Pr�ram Record ID r /2 5 ,3 /,0jot? `d ( It 1 Facility Address (Please Check the appropriate description and specify size, number of units and pertinent information) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending 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 If License # Sticker # ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration # License # Sticker # _ ❑ Temporary Food Facility -----Dates of operation from = to ❑ Special Event —Dates of operation from to ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dalry ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) IIAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle f Exempt System (2299) ❑ CRT Offsite Handlers (2219) ❑ 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) ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units Employee housing (2700) Use Employee Ifousin,g/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RNVQCB 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 1 ❑ Kennel TATTOO BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100)1S"ZiJ J7 Tattooing (4121) pR�fS g 'p Body Piercing (4120) ' I� )}j��,, —2 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) ❑ Landfill ❑ 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 11 Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2 -10 ❑ 11- 60 ---❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form J EMERGENCY NOTIFICATION F R Tri15 FACT 1TY ANDIOR PROGRAM CONTACT PERSON (/� sei Cq t/Ct rf 16�ti:CtZ Ph 2U cl 7-11- �T 353 Night Ph PROGRAM ELEmE,,NT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# `-I PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date INVOICE # 0 Cash RFviF-WEb BY ACCOUNTING OFFICE Date