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SAN JOAQUIN COUNTY El RON�IENTAL HEALTH DEPAR" ANT <br /> MASTERFILE RECORD INFOM'YIATIO-N FORM <br /> New EH Pro�am at Existin Facility ❑New EH Program and New Facility <br /> Facility ID F (( �i v Program Record ID fl <br /> Facility Address -3 "1071 +tty <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Square Footage Food Handlers Course required: -YEs❑ No El - <br /> ❑Restaurant: Seating Capacity 9 <br /> ❑ Commissary ❑ Dry storage only 11 with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle-----Make Sticker# <br /> Registration# License,_ <br /> Vehicle Type Color <br /> ❑ Mobile Food Prep Unit--Make Sticker# <br /> Registration# License <br /> to 11 Ice Plant <br /> El Temporary Food Facility-----Dates of operation from ❑ Produce Stand <br /> ❑ Special Event --Dates of operation from <br /> to <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) ❑ Recycle/Exempt System(2299) <br /> El Hazardous Waste Generator------------Tons Generated Per Year } _�17) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2_ <br /> Tiered Permitting Facility ----- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fired Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> 1ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution--Number of Units <br /> [I Hotel/Motel-------Number of Units <br /> mp Applications Form <br /> Employee Housing(2700) Use Employee t/ousine/Labor Ca <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11 Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ElNPL/SEP Cleanup Site [IUIC Site <br /> ❑ R��QCB Cleanup Site ❑ Water Quality Remediation Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site <br /> RECREATIONAL HEALTH PROGRAM(3600) El Bathing Area <br /> Number of Pools/Spas at Facility El Pool 11 spa ❑ Out of Service Pool/Spa b <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) ElBody Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle', <br /> ❑ Pumper Vehicle--Registration# License# P Y <br /> ❑ Package Treatment Plant 11 Chemical Toilets-------Number of Units <br /> [I Pumper Yard <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> 11 Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ Process/Recycle Facility [I CIA Landfill Site <br /> ❑ Waste Tire Facility El Compost Facility ElFarm/Ranch Cleanup Site <br /> El Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 11 Large Generator ❑ Sma------ Generator <br /> r 0>'60g d Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----02- 10---"-"" <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PJVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> Cl Surcharge FEE ❑ Other FEE <br /> PROGRAM ELEMENT 1 ?, o FEE t0 PERMIT VALID <br /> El Food Handler <br /> INSPECTOR# ��� � INVOICE# <br /> 11 Check# AMOUN Date /y <br /> Date <br /> ❑ Cash REVIEWED BY <br /> ACCOUNTING OFFICE !/ <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />