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SAN JOAQUIN COUNTY k 'IRONMENTAL HEALTH DEPAI,...WIENT <br /> MASTERFILE6ECORD INFORMATION FORM <br /> ❑New EH Pro am at Existing Facility w EH Pro am and New Facili <br /> tv <br /> Facility m rA o o M baa Pro ram Record ID <br /> Facility Address M ILII 1142 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) UNTY <br /> ❑Restaurant: Seating Capacity Square Footage U4-­''0 i,I�-N T A L_, <br /> ❑ Commissary ❑ Dry storage only El with Food Preparation Food Handlers Course t)ir�di DVAS T►7t.F <br /> P ❑Vending Machines-Number of Units <br /> ❑Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ 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 <br /> ❑ Special Event --Dates of operation from 11 Ice Plant <br /> to 1:3 Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy V Milk Dispenser--Number of Containers in Mufti-Head UnitCOPA State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ).hazardous Waste Generator------------Tons Generated Per Year Ge�El Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <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 <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A 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 Housine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND 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) <br /> ❑ Poultry Farm—Maximum number of birds <br /> ❑ Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> 114UID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> El Pumper Yard ❑ Package Treatment Plant 11Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd ----Number of Units ❑ Farm/Ranch 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-----❑ 11 .60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS END 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 7-7 FEE 1-7-I-O l7 ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# D 1 Sr T PERMIT VALIDI t I (O L- to L Y 3 1(O L 11Food Handler <br /> ❑Chwk# AMOUNT PAID IJ//11 I L ILGZ Date 311 L(O INVOICE#- ( q-M 7 <br /> ❑Cash REVIEWED BY AccouNTrsicOFFICEDate 3 /Lo I C)(� <br /> 48-02-034 Masterfile Record Pink <br /> 10/6/2003 <br />