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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New Ell Program at Existing Facility <br />Facility ID -EIVO <br />Facility Address <br />(Please Check the appropriate decription and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market —Square footage <br />0 Mobile Food Vehicle --Make <br />License if <br />II,Mobile Food Prep Unit—Make ('frk V yehicle Type <br />Registration If 167 grfp32.k g.43/64t8,_c License It 71-I <br />El Temporary Food Facility —Dates of operation from to <br />Special Event —Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />0 Hazardous Waste Generator. —Tons Generated Per Year <br />0 CRT Offsite Handlers (2218) 0 Silver Only (2222) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) <br />0 Permit-By-Rule Fixed Unit <br />0 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 />0 Hotel/Motel —Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local HVV Cleanup Site NPL/SEP Cleanup Site 0 UIC Site <br />0 Abandoned IlW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site • <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />o Pumper Vehicle—Registaation if License if Capacity Vehicle if <br />El Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag / Cannery Waste Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />0 Refuse Vehicles —Number of Units 0 Dumpsters >20 cu yd —Number of Units <br />Registration it <br />Square Footage Food handlers Course required: YES 0 No 0 <br />0 with Food Preparation 0 Vending Machines —Number of Units <br />0 with Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />Sticker /I (0 <br /> Color <br />Sticker if <br />DNew Eli Program and New Facility <br />Program Record ID f S=4 1 <br />0 Milk Dispenser—Number of Containers in Multi-Head Unit <br />0 Jail or Exempt Institution —Number of Units <br /> Recycle (Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Household Hazardous Waste <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />PA <br />F•?' l i ft% <br />FE8 r "1) <br />J 2009 <br />1-14AlkilRogAlm/A147.0,L1471, <br />ARTmE.1-Nr <br />0 Ice Plant <br />0 Produce Stand <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care <br />Transfer Station 0 Veterinary Clinic <br />0 Skilled Nursing <br /> 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Common Storage Facility-0 2 - 10 — 0 1i- 60 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PH'S EITI) 46-02-003 Blue Application Form <br />EMT GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph CONTACT PERSON <br />PROGRAM ELEMENT /63_L--- FE <br />INSPECTOR # PERMIT VALID <br />Check # AMOUN AID l,l <br />Cash <br />REVIEWED BY <br />0 Surcharge FEE 0 Other FEE <br />to \ I 0 0 Food Handler <br />Date 2--( 2—S b 9 M.-- INVOICE /I 1r 31 <br />Date ACCOUNTING OFFICE <br />NA,ctrrfilp Pt.rnrrl Ph*