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0 New EH Program at Existin Facility <br />Facility ID <br />Facility Address <br />New EH Program and New Facility <br />Program Record ID <br />(i\i'cke P-o'k )("A'i <br />p,cpooci L,17 <br />SAN JOAQUIN COUNTY Er. .RONMENTAL HEALTH DEPARTAILF,NT <br />MASTERFILE RECORD INFORMATION FORM <br />S—S4d€ <br />(Please Check the appropriate description and specify size number of units and pertinent information.) <br />FOOD PROGRAM (1600) 0 <br /> <br />ID Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation 0 Vending Machines --Number of Units <br />0 Retail Market --Square footage 0 with Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration if License if <br />0 Mobile Food Prep Unit—Make Vehicle Type <br />Registration # License if <br />0 Temporary Food Facility --Dates of operation from <br />Special Event --Dates of operation from to <br />DAIRY PROGRAM (2000) <br />CUPA 0 State Facility Surcharge (2399) <br />0 Milk Dispenser— umbe of Contain7inulti9lei4 Unit <br />0 Silver Only (2222) 0 Appliance Recyclers (2217) <br />0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <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 El Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />El Environmental Assessment 0 UST-CAP Site 0 Local IIW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />0 Abandoned IIW Site 0 non-NPL/SEP 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 />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 />Pumper Vehicle--Registration if License if Capacity Vehicle if <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag / Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles --Number of Units 0 Dumpsters >20 Cu yd --Number of Units 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility-0 2 - 10 ----- - 60 -----0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use MI'S EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT 2310 FEE 0 Surcharge FEE 0 Other FEE <br />iNspEcToR# Drto PERMIT VALID to 0 Food Handler <br />0 Check # AMOUNT PAID Date INVOICE # <br />0 Cash REVIEWED BY ACCOUNTING OFFICE Date <br />48-02-034 Masterfile Record Pink <br />Sticker it <br />Color <br />Sticker # <br />to 0 Ice Plant <br />0 Produce Stand <br />Grade A Dairy 0 Grade B Dairy <br />(-) HAZARDOUS WASTE PROGRAM (2200) t- 0 Hazardous Waste Generator-----------Tons Generated Per Year <br />0 CRT Offsite Handlers (2218) <br />Tiered Permitting Facility <br />0 Recycle / Exempt System (2299) <br />innrs,