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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM V5-New EH Program at Existing Facility ❑New EH Program and New Facility Facility IDEA Program Record ID PZ 53 (. t L Facility Address (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaumat: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units ❑Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration it License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ____ ❑ Ice Plant ❑ Special EYeat --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Mill:Dupeuser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑Hazardous Waste Generator.-=— Tons Generated Per Year ❑Recycle f Exempt System(2299) ❑CRT,Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(221 7) Tiered Permitting Facility ❑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) ❑ Hotel/Ifslotel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Ifousing4obor Camp Application Forst 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 ❑Nater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑Poo1 ❑ Spa ❑Out of Service Pool(Spa ❑Natural Bathiug Area VECTOR CONTROL PROGRAM(4000) 11 Poultry Fara Maximum number of birds 11 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 ❑ Sludge/Ash Site ❑Waste Tire Facility 11 Compost Facility 11Process(Recycle Facility ElCIA-LandfillSite ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) 13 Primary Care ❑Acute Care Skilled Nursing ❑Large Generator ® Small Generator ❑ Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-N ❑ 11-60---❑>60 generators PUBLIC WATER_ SYSTEM PROGRAM(4600)Use PJVSEHD46-02-003 BlrceApplicalion Form EMERGENCY NOTIFICATION FORTHts FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROcm_4AtELEI\1ENT .JAG FEE 4 1703 Dq' ❑ Surcharge FEE'- ❑ OtlierFEE _ INSPECTOR# -ZA9 _ PERMIT VALID l / (( to � e I r!I ❑ Food Handler s C1 ('heck t, A-T\IOUNT PAID ,` [ Date INVOICE# El Cash_ __ RENIIEVlED BY =v ___ACCovNriw,OFFICE v DatejL L___