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SAN JOAQUIN COUNTY F"IRONMENTAL HEALTH DEPART NT MASTERFII_ CORD INFORMATION FORM �'❑ New EH Program at Existing Facility ❑New EH Program and New Facility II Facility ID S 6 Pro ram Record ID Q� Facility Address IMA7244W5 �P;!; (Please check the appropriate description and specify size, number of units and pertinent information.) DSAil V4y FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No Ci (� ❑ 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 !I Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# !! ❑ Temporary Food Facility--Dates of operation from to Q Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand II DAIRY PROGRAM (2000) .. ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head d Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM (2200) :I ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) II Tiered Permitting Facility------------------- ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste XABOVEGROUND STORAGE TANK FACILITY(AST) (2390) Number of AST UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use USTA and B forms r i HOUSING PROGRAM (2400) 'I ❑ HotellMotel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee HousinW/Labor 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 Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) I' ❑ Poultry Farm-------Maximum number of birds ❑ Kennel II . TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) I ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics(4.122) LIQUID WASTE PROGRAM (4200) 41 ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) li ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#or units) ❑ Dumpsters>20 cu yd (#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 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form d EMERGENCY NOTIFICATION FOR THIS FACILITYANDIOR PROGRAM �! CONTACT PERSON Day Ph Night Ph I PROGRAM ELEMENT 2� �CT FEE © Surcharge FEE ❑ Other FEE INSPECTOR PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE#f ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-42-034 MASTERFILE RECORD INFORMATION PINK 11 H 5ID7 .I