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SAN JOAQUIN COUNTY El TRONIVIENTAL HEALTH DEPART"LENT <br /> MASTERFILE RECORD INFORNIATION FORM <br /> ew EH Program at Existing g Facili <br /> ❑New EH Program and New Facility <br /> Facility ID TA 150 Is 5 t Pro ram Record ID <br /> Facility Address LIQ as sc F L4 e)? <br /> (Please Check the appropriate description and specify size,number 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 ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ prepackaged Goods Only <br /> Vehicle Type Colo <br /> ❑ Mobile Food Vehicle Make License# Sticker# <br /> Registration# Color <br /> �- <br /> ❑ Mobile Food Prep Unit Make License"Vehicle TypeSticker# <br /> Registration# r ❑ Ice Plant <br /> ' ❑ Temporary Food Facility-----Dates of operation from to -8 produce Stand <br /> ❑ Special Event --Dates of operation from <br /> to <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUP p ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)- ❑ Recycle/Exempt System(2299) <br /> ❑Hazardous Waste Generator------------Tops Generated Per Year ❑ Appliance Recyclers (2217) <br /> ❑ CRT Offsite Handlers(22 t 8) ❑ Silver Only(2___) PP <br /> Tiered Permitting Facility— El Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) - <br /> ����........,,,,/// ❑ Permit-By-Rule Fixed Unit ❑ Perini[-By-Ru <br /> 1� le Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST i <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOLISM_ G�M(2400) <br /> - ❑Jail or Exempt Institution—Number of Units <br /> ❑ HotellMotel-------Number of Units - <br /> P Application Form <br /> Employee Housing(2700)Use Employee Housine/Labor Cam <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 13 Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site E] UIC Site <br /> up Site 13RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> 11 Abandoned HW Site Cl yon-NPL/SEP Clean <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm--Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE pRoGRAM(4200) Ca acit Vehicle# <br /> ❑ Pumper Vehicle--Registration#_�— License# P Y _ <br /> ❑ Package Treatment Plant [3 Chemical Toilets-------Number of Units <br /> [I Pumper Yard _ <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill <br /> ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> ❑ Compost Facility ❑ Process/Recycle Facility <br /> ❑ Waste Tire Facility P ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd---Number of Units <br /> MEDICAL WASTE PROGRAM(4500) Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Primary Care Ll Acute Care ❑ Skilled Nursing ❑ Large ❑ 1 I 60-----13 >60 generators <br /> ❑Transfer Station ❑ Veterinary Clinic <br /> [3Common Storage Facility-----02- 10------ <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P '5 EHD 46-02-003 Blue Application Fornt <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> Day Ph ht h <br /> CONTACT PERSON El Other FEE <br /> � ❑ Surcharge FEE <br /> PROGRAM ELEMENT Z.� FEE to IT VALID <br /> PERM ❑ Food Handler <br /> -- <br /> jNSPECT717 <br /> DR# '() jNVOICE# <br /> I1NT PAID Date <br /> ❑Chcck# DatC <br /> REVIEWEB ,1. 'G OFFICE <br /> [I Cash DMast tle Record Pink <br /> 48-02-034 <br /> 10161 <br />