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SAN JOAQUIN COUNTY ENVIRONMI{JNTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORI1� New EH Program at Existing Facility ❑New EH Program and New Facility Facilit•ID FA Program Record ID b �� Facility Address T x:21 11 (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 C7 ❑ Commissary ❑ Dry storage only El with Food Preparation ❑4Tending Machines—Number ofUnits ❑Retail Market---Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# C❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to 11 Ice Plant ❑ Special Event —Dates of operation from to 11 Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy, ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200)' I ❑hazardous Waste Generator.. Tons Generated Per Year ❑Recycle I Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) __ ❑ Appliance Recyclers(2217) Tiered Permitting Facility C❑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 Corms HOUSING PROGRAM(2400) {❑ Hotet/11Iote1 Number of Units -❑Jail or Exempt Institution Number of Units Employee housing(2700)Use Employee KousinelLabor Camp Applications Forma SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑Environmental Assessment ❑UST-CAF Site ❑Local HW Cleanup Site. ❑NPLfSEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB 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) El Poultry Farm Maximum number of birds ®Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) 11 Tattooing(4121) 11 Body Piercing(4120) [1 Perrrranent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License f€ Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) 11 Landfill 13 Transfer Station ❑Ag/Cannery Waste Site 11 SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site ❑Defuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care Skilled'Nurs'mg ❑Large Generator 0 Small Generator ❑Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use Pif'SEHD 46-02-003 B1rreAppticafiors Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph I'ROGR4MELER1EriT __ FEE 4103 a C7j? ❑ Surcharge FEE '- ❑ Other FEE — INSPECTOR#��Z� PERMIT VALID I [L1.__ to �� 1 ElFood Handler_p. 11 Chect AMoUNTPaIJ tLL — 'Date INVOICE# Atf I F-1 Cash Rrvrs�'rEv BY ACCOUNTING OFFICE -- Dat(,_