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0 a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existiag Facility ❑New EH Program and New Facility <br /> Facilit°ID A CO b 'l I Pro ram Record ID P f�-o O L'(S'2--- <br /> facility Address X5,11 Vni42trb0t�&r fls-" S--064kIIN <br /> (Please Check the appropriate description and specify sizenumber 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 11with Food Preparation ❑rending Machines—Number of Units <br /> ElRetail 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 /> 11Temporary Food Facility—Dates of operation from = to 11 ice 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 /> GUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' t <br /> ❑Hazardous NVaste Generator.--Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) 1 ❑ Appliance Recyclers(221 7) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous SVaste <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 /> [IHote1/111ote1 Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Fmployee Ifousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ®NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned I1W Site ❑non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater 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 /> 11Poultry Farm Maximum number of birds ❑Kennel <br /> `TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4 120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant. ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill 11 Transfer Station 11 Ag/Cannery Waste Site 11 Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu.yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> EJ Primary Care ❑Acute Care KSkilled'Nurs"mg 11 Large Generator C] Small Generator ❑Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use f JVSEND 4G-02-003 BlueApplicalion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGR4MELENIENr U5aq_ FEE �� ❑S7US-1 <br /> eFEE ❑ Other FEE <br /> INSPF_CTQR# Ab��_ PERMIT VALID x to 1 ❑ Food Handler_ e-- <br /> U Check i, i.A.2Y,Iou i r P kID � _ Date INVOICE# <br /> ❑ Cash REVIEWED BY � '� ACcoVNTlra r OFFICE -_ Date <br />