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Ali AMC <br /> SAN JOAQUIN COUNT 'NVIRONMI ENTALEEALTH DIVWON <br /> MASTERFILE RECORD INFORMATION F61ieI(EH 00 691 <br /> New EH Program at Existing Facility - ❑New EH Program and New Facility <br /> FacilityID D U13'5 '1 Program r Record rD 2D 9-751 <br /> FacilityAddress I2S5 S 21)L <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yrs❑ No 11 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation - [Wending Machines—Number of Units <br /> ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments Q Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ MilkDispenser—Number of Containers in Multi-Head Unit- <br /> COPA. ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200). <br /> ❑ Hazardous Waste Generator------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST 9 — <br /> UNDERGROUND STORAGE TA INK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housin/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDFRGR06NO INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <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(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Slud e/Ash Site <br /> C3 Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site g <br /> ❑ Waste Tire Facility ❑ Compost Facility cle <br /> ❑ Process/Recy Facility Facili ❑ CIA Landfill Site <br /> � <br /> ❑ Refuse Vehicles—Number of Units [IDumpsters>-0 cu yd—Number of Units ❑ FarmlRapeh Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- 10—❑ l I -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS£H0069 Blue Application Form <br /> I EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON "1 N V f L( N 1 Day Ph 365 Night Ph <br /> PROGRAM ELEMENT FEE 13 Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 193t —7 PERMIT VALID to ❑Food Handler_ <br /> ❑ Check# Ai iowr PAID Date INVOICE# r <br /> ❑ Cash REVIEWED BY ACCOUN-II.1G OFFICE Date �7 <br /> Rev.07107i99 <br />