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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />PAW A <br />REn' <br />AfNew EH Program and New Facility A p, 1 <br /> <br />sAA, u <br /> <br />. 8 <br />Ma.0_,AMPIPS-411r1r 4q.'Al 40Q1j/A/ CO LT, (Airy <br />rl 003,:::1VrAt <br />'11.1714E-Arr <br />0 New EH Program at Existing Facility <br />f:60:;22-1111:01 <br />Facility ID (-- 0 0 , g Program Record ID <br />ed 1 <br />It <br />d specify size, number of units and pertinent information.) <br />Food Handlers Course required: YES 0 NO 0 <br />0 Vending Machines —Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Registration # License # <br />0 Mobile Food Prep Unit—Make Vehicle Type <br />Registration # License # <br /> Sticker # <br />0 Temporary Food Facility —Dates of operation from <br />Li Special Event —Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />0 Hazardous Waste Generator. —Tons Generated Per Year 0 Recycle Exempt System (2299) <br />0 Appliance Recyclers (2217) Li CRT Offsite Handlers (2218) 0 Silver Only (2222) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />0 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 />0 Hotel/Motel —Number of Units 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Ifousing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local IIW Cleanup Site. El NPL/SEP Cleanup Site <br />0 Abandoned IIW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 16 iga Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Piercing (4120) <br />License # <br />0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility <br />0 Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Veterinary Clinic 0 Common Storage Facility--0 2 - 10 —0 11 -60 —0 >60 generators <br />Facility Address <br />(Please Check the appropriate decription an <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market —Square footage <br />0 Mobile Food Vehicle ----Make <br />Square Footage <br />0 with Food Preparation <br />0 with Meat Market only <br /> <br />Vehicle Type <br />Sticker # <br />Color <br />to Ice Plant <br />0 Produce Stand <br />0 Grade B Dairy 0 Milk Dispenser—Number of Containers in Multi-Head Unit <br />0 UIC Site <br />0 Water Quality Remediation Site <br />0 Tattooing (4121) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper Vehicle—Registration # <br />0 Pumper Yard <br /> Capacity Vehicle # <br />0 Chemical Toilets—Number of Units <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />0 Permanent Cosmetics (4122) <br />0 Ag / Cannery Waste Site 0 Sludge/Ash Site <br />0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Dumpsters > 20 cu yd —Number of Units 0 Farm/Ranch Cleanup Site <br />0 Primary Care <br />0 Transfer Station <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS ELM 4642-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDfOR PROGRAM <br />Day Ph 4 7 3 — cn Night Ph Z 5 778/ <br />0 Surcharge FEE 0 Other FEE <br />) 0 Food Handler <br />INVOICE /f S 1/1.0 S <br />Date Lk( <br />1 t7ttoi 604 -1 L,S 6 663 'ttsr.ig N4nct,r£11, Req-nrd Pint- <br />CONTACT PERSON \\\ <br />PROGRAM ELENIENTN 14154 *if 391VFEE 191. C <br />INSPECTOR U PERMIT VALID . t <br />0 Check U AMOUN PAID 0E. s <br />0 Cash REVIEWED BY <br />to <br />Date <br />ACCOUNTING OFFICE <br />/ 66