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` l <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility New EH Program and New Facility <br /> Facility ID OID Pro ram Record 7 2'� <br /> Facility Address (Tp� R5t4&TA <br /> (Please Check the appropriate description and specify s-__Ks number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food HandlersCourse required:. YES❑ No 11 <br /> ❑ Commissary ❑ Drystorage only ❑with Food Preparation ❑Pending Machines Number of Units <br /> ❑Retail Market---Square footage ❑with Meat Market only ❑Multiple Departri ents ❑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 ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(20W) <br /> ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator- Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑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 Waste <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 /> ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housinbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment Q UST-CAP Site ❑Local HW Cleanup Site, ❑NPL/SEP Cleanup Site ❑UTC Site <br /> ❑Abandoned HW 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 PoollSpa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm—Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑SludgelAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site <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 ❑Skilled Nursing Large Generator ❑ Small Generator ❑Limited Hauler <br /> 11 Transfer Station E3 Veterinary Clinic 1:1 Common Storage Facility--0 2-10-1111-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EMD 46-02-003 Blue Application Form <br /> RMERGENCY NOTIFICATION FOR rms FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON 2� Day Ph Night Ph <br /> PROGRAM ELEMENT S, FEE m ❑Surchfa a FEE ❑ Other FEE <br /> INSPECTOR# PERMITVALID r 1 to IoL © ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> 13 Cash REviEwFb BY ACCOUNTING OFFICE Date $' <br />