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SAN JOAQUIN COUNTY ENVERONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Fmility, 11NewEHPmgmrnandNew adity lFacilityID r&002 q 3'I q Program Record ID to2.0 5 14,1 FacilityAddress a3—�sC . lZ�k 6A 9;5-?,05— (Please l;57-vim(Please Check the appropriate description and specify sin,number of units and Pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No❑ ❑ Commissary ❑ Drystorage 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# License# Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility---Dates of operation from to ❑ Ice Plant ❑ Special Event--Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility-------❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) _ ,�� ❑ Permit-By-Rule Fixed Unit El Permit-By-Rule Household Hazardous Waste L7ABOVEGROUND STORAGE TANK FACILITY AS 2390 Number of AST (AST) ) 2, �Dtr_7ot2o� GLie.Se.Q UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms I O<)D HOUSING PROGRAM(2400) cd&-s ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee HousimalLabor Cantu Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑ Local BW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑ 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# 11 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 ❑ Compost Facility ❑ Process/Recycle Facility ❑CIA Landrdl Site ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ 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 PWS EMD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 8--10 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 8c`Nq PERMIT VALID to ❑ Food Handler ❑Check# AMOUNT PAID Date INVOICE# p' ❑Cath REVIEWED BY ACCOUNTING OFFICE 3 Date 48-02-034 Masterfile Record Pink 10/6/2003