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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORM <br /> Iew EH Program at Existia Faacility ❑New EH Program and New Facility <br /> Facilit•ID �D QQ Program Record ID � 9 <br /> facility Address I O s 1 -NA G <br /> (Please Check the appropriate description and specifye,number of its and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only Elwith 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 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 /> 11Special Event --Dates of operation from to 11 Produce-Stand <br /> DAIRY PROGRAM(20W) <br /> ❑ Grade A Dairy, ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' <br /> ❑hazardous Waste Generator..— Tons Generated Per Year ❑ Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pen-nit-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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> [IIlotenjoteI Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Housing- bor Camp Applications Fora <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site, ❑NrusEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑ non-NPIJSEP Cleanup Site ❑RNVQCB Cleanup Site ❑Nater 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 Farina Maximum number of birds 11 Kennel <br /> TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑Body Piercing(4120) ® Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> 11 Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag f Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfall Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> Primary Care ❑Acute Care ❑Skilled'Nursing ❑Large Generator El Small Generator ❑ Linuted hauler <br /> L01,❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--11 2-10 ❑ fl-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePiVSE11D46-02-003 BlueAppticariorz Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT "`S FEE ❑ SurchargiFe1E - ❑ Other FEE _ <br /> INSPECTOR# ERM.1T VALID�0.0. i 1 to ,�/ 1 ❑ Food Handler <br /> Check# AIt Ul`rr P At D eh Date IIWOICE# (S .--- <br /> F 17 Cash IUVIEWFDIII <br />