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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD-INFORMATION FORM New EH Pro ram at Existing.Facility ❑blew EH Program nada New Facility Facility ID WS Program Record ID Facility Address 1 SO /V SYIV G.L A! fZ A (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square 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 ElPrepackaged 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 froth to ❑ Ice Plant Q Special Event --Dates of operation from to 0,Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Mille Dispenser---Number of Containers in Multi-Head Unit i CUPA ❑ State Facility Surcharge(2399) IiAZARDOUS WASTE PROGRAM(2200) ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2219) []Silver Only(2222) ❑Appliance Recyclers(2217) ZABOVEGROUND, Permitting Facility i]Conditionally Authorized(CA) 11nditionally Exempt(CE) El Permit-By-Rule Fixed Unit a 't-By-Rule Household Hazardous Waste STORAGE TANK FACILTTY(ASI)(2390) Number of AST Z� .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B o s HOUSING PROGRAM(2400) ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Em toee Housing/Labor Cam A lication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑Environmental Assessment ❑UST-CAP Site 13 Local RW Cleanup Site. [3NPLISEP Cleanup Site 13 UIC Site ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RIVQCB Cleanup Site 4❑ Yater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PoolslSpas at Facility. ❑PQoI ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR.CONTROL PROGRAM(4000) ❑ Poultry Farm Maximurn number of birds ❑Kennel TATTOO,BODY PIERCING,PERMAHEN_T COSMETIC PROGRAM(4100) ❑Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑Pumper Yard ©Package Treatment Plant- 13 Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill © Transfer Station ❑Ag 1 Cannery Waste Site ❑ SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CTALandfill Site ❑Refuse Vehicles Number of Units ❑ Dumpsfers>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing 13 Large Generator Small Generator IJ Limited Hauler 11 Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM!(4600)Use PWS FLLD d6-02-003 $fueALyplication Form (EMERGENCY NOTIFICATION POR THIS FACILITY ANDIOR PROGRAM CON'T'ACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR#f 7i ERMIT VALID . to ❑Food Handler ❑ Check# ' AMOUNT PAID Date INVOICE I# ❑ Cash REvizwEb-BY ACCOOUNi'ING 0 FFICE Date a -- --- KAecr—M,IZ�nnrA Pink