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I— SAN JOAQUIN COUNTY '�_`VIRONMENTAL HEALTH DEPAP;F SENT MASTERFIL4ECORD INFORMATION FORM ` ar ❑ New EH Program at Existing FacilitX ❑New EH Program and New Facility Facilit iD Pro ram Record ID o2 Facility Address 2,/'10 - Gv IV (Please aleck the appropriate description and specify size,number of units and pertinent information.) FOOD PAGRAM(160 0) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ RetailMarket----Square footage ❑ with Meat Market only ❑ Multiple Departments[] Prepackaged Goods Only ❑ Mobill Food Vehicle–Make Vehicle Type Color Registration# License# Sticker# ❑ Mobil Food Prep Unit Make Vehicle Type Calor i Registration# License# Sticker# ❑ TemplOrary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PRGRAM (2000) ❑ GradigA Dairy ❑ Grade B Dairy 11Milk Dispenser-Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM (2200) D Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) © CRT Offsite Handlers(221 S) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) Q ❑ Permit-By-Rule Fixed Unit ❑ Permit-By- ule Household Hazardous Waste )VABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B form (– HOUSINGIPROGRAM(2400) 11HotelkAotel—Number of Units ❑ Jail or Exempt Institution ----Number of Units Employeej Housing(2700) Use Employee Housinv/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ AbaJoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREAliONAL HEALTH PROGRAM (3600) Number cif 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-i$ODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID W TASTE PROGRAM(4400) ❑ Lancift ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ WastgTire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site MEDICAAWASTE PROGRAM(4500) ❑ Prima,' Care 1:1 Acute Care ❑ Skilled Nursing 13 Large Generator 13 Small Generator El Limited Hauler ❑ TranJer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue A0,01ication Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT Z �Lb FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# -13-07PERMIT VALID to ❑ Food Handier ❑ Check% AMOUNT PAID Date INVOICE# ❑ Cash I REVIEWED BY ACCOUNTING OFFICE Date d' 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07