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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility . ONcw EH Pro m and New Facility Facilit ID- Program Record ID Facility Address (Please Check the appropriate description and specify IjLe,number of units and pertinent information) FOOD PROGRAM(1604) ❑Restauraut: Seating Capacity Square Footage Food Handlers Course required:- Yrs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation Oven'ding 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# License# Sticker# ❑Mobile Food Prep Unit Make Veli.icle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenses Number of Containers in Multi-Head Unit w_CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2204) ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally EXCUTt(CE) ❑Permit-By Rale Fixed Unit 0 Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(ASI)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B rorms HOUSING PROGRAM(2404) ©Hotel/Motel Number of Units 13 Jail or Exempt Institution Number of Units Employee Housing(2704)Use FmployeeHousirre/La6or Camp Anpllc adon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site• ❑NPLISEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑non NPLISEP Cleanup Site ❑RNVQCB Cleanup Site ❑Water Quality Remediation Site RECRFJi ZONAL HEALTH PROGRAM(3604) Number of poolslSpas at Facility- ❑Pool E3 spa Out of Service PooVSpa ❑Natural Bathing Area VECTOR.CONTROL PROGRAM(4040) ❑Kennel ❑ Pouitry Farm Maximum t►umber of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) ❑ Tattooing(4121) Cl Body Piercing(4120) ID WASTE PROGRAM-( a � Vehicke# umperVesicle-RLicense#,: � � Cpacity ❑Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) 13 Laadfilk ❑ Transfer Station ❑Ag/Cannery Site ❑sludge/Ash Site - ❑Waste Tire Facility 11 Compost Facility ©Process/Recycle Facility ❑ CIA,I.andfill Site ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Rauch Cleanup Site MEDICAL WASTE PROGRAM(4$00) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10 ❑ 11-6o----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PII'S F,11D 46-02-003 Blue Apelicadarr Form FmFpr,EN Y N0TwtcATioN r•OR TIims r ILITY ANDIOR PROGRAM CONTACT PERSON ` e�)— Day P cjO fight Ph P'ROGRAm ELEMENT 4 Cr,FEE `01 Sol D ❑ Surcharge FEE CI Other FEE iNSeECroR# :3L to PERMIT VALID . 1>1100,F, to t�31(�Y _ ❑Food Handier_4 ❑ Check# AMOUNTPAID 4 6tLl t0 _ Date_j;?::j 1916E INVOICE# ❑ cash RF-vmwED BY AccouNTING OFFICE ' Date