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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT NOV 0 y VED MASTERFILE RECORD INFORMATION FORM ❑New EH Programat ExistingFacility ew EH Program and New Facility "PAQU11y c?Q�Q Facility ID 61 V 090 ` Program Record ID/ D pA4,, OU Facility Address (Please Check the appropriate description and specify Elm numbe of units and pertinent information.) FOOD PROGRAM(1600) []Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ No ❑ ❑ Commissary 11 Dry storage Only ❑ with Food Preparation ❑Vending 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 Vehicle 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 Dispenser—Number of Containers in Multi-Head Unit -..CUPA ❑ State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) y" ❑Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle f Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑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) ❑HotcVMotel Number of Units -❑Jail or Exempt Institution—Number of Units Employ"Rousiag(2700)Use Employee HousinglLabor Camp Application Form SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) -❑ Environmental Assessment ❑UST-CAP Site ❑Local BW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site ❑ Abandoned IINV Site ❑ non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) - - Number of Pocls/Spas at Facility. ❑P901 ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area- VECTOR CONTROL PROGRAM(4000) - ❑ Poultry Farm—Maximum number of birds ❑ Kennel TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑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 ❑ProcesslRecycle Facility ❑ CIALandfrll 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 ❑ Small Generator ❑Limited hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-10—❑ 11-60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS F11D 46-01-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Nigbt Ph PROGRAM ELEMENT �6 Y FEE ` ' 6 L1Surcharge FEE El Other FEE INSPECTOR# PERMIT VALID ,V IT I L) to l\I 3_-_ /_� 11 Food Handler ElChcck# ATIOUNT PA `. (n Date �,U 41 VO ��r-lr INVOICE# 40 r>%/0 a f' Cash REVIEWED BY �C�ACCOUNTING OFFICE Date it