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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM 40. New -H Program at Existing Facility ❑New EH Program and New Facility 'Q Facile ID Program Record ID S v� AA ��4 Facility Address 1(C� Y�{.�;r�� (��I _ ,�V,� �0�, :4 (Please check the appropriate description and specify size, number of units and eminent information.) y T✓I��(/,N Oel FOOD PROGRAM(1600) tio�H yE�90 [] Restaurant Seating Capacity Square Footage Food Handlers Course required: Yes 'Np-lb- ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units FtiT ❑ Retail Market—Square footage ❑ with Meat Market onfy ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# © Temporary Food Facility-Dates of operation fr-m to . ❑ Ice Plant Special Event Dates of operation from_ �L � to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) — ❑ Silver Oniy(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility--------�]i Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST) (2390) Number of AST UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM(2400) ❑ HotellMotel—Numberof Units ❑ Jail or Exempt Institution---Number of Units Employee Housing (2700) Use Employee HousinglLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL~(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of POoISISpas at Facility ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm--Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle.Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station © Ag/Cannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles[*of Units) �EJ7 Dumpsters a 20 cu yd(#of units) _J ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing © Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PINS EHO 46-02-003 Blue Application Form _ EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph �P,_ r � {t�I Night Ph PROGRAM ELEMENT 1 FEE i - ❑ SurchargeLfF ❑ Other FEE INSPECTOR# ,tug PERMITVAiID to `T� El Food Handler ❑ Check# Vj AMOUNT PAID �,Z• a Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 3 4&O2-434 / MASTERFILE RECORD INFORMATION PINK 11115W