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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility Vew EH Program and New Facility <br /> Facilif ID 1::-Pr C)p-�c g `` PropgramRecord ID .53622-3: - <br /> Facility Address —T ��( ___d a t—Zk Z.0G{f. <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food handlers Course required:-. YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation 11 Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Iee Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS NVASTE PROGRAM(2200)' <br /> ❑hazardous NVaste Generator.. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous lVaste <br /> ❑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 /> ❑HotelfMotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Eanployee Housing(2700)Use Employee Housin.Kabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL( 000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑Local MV Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HAV Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL.HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds El Kennel <br /> TATTOO 13ODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License f- Capacity Vehicle# <br /> ❑ Pumper Yard ®Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑ SludgelAslr Site <br /> ❑Waste Tire Facility 11 Compost Facility 11Process/Recycle Facility 11CIA-LandfillSite <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Shilled'Nursing Large Generator 0 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--El 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVSEHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON_ Day Ph Night Ph <br /> PROGR_&Nt ELEh'IENT_ FEE<8 ❑ Surcharge FEE ❑ Other FEE _ <br /> INSPECTOR# PERMIT VALID—117/ to / �1�1 l/ ❑ Food Handler <br /> 11 Check g Al, T>UNT PAID ( _ IJate IWVOICE 4 2 _ <br /> t ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 7-I <br />