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SAN JOAQUIN COUNTY EN,.,RONMENTAL HEALTH DEPAR',,,,ENT <br /> MASTERFELE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Proom and New Facility <br /> Facfllity ID 91 Program Record ID O`a <br /> Facility Address �(t'1��7 A r�er Wn+ !j <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation [Wending 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 ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) - <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) / '( �L-+• <br /> Hazardous Waste Generator------------Tons Generated Per Year C f 1J Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221 g) ❑ 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 Hoasine/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 ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4 100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard I ❑ Package Treatment Plant ❑ Chemical 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 PWSEHD 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR TNIS FACILITY AND/OR PRO M <br /> CONTACT PERSON (QONQLp eiAlf Day Ph '2?`7- ht Ph <br /> PROGRAM ELEMENT <br /> '2- i Z V FEE Z ( 3• t� oSurchar a FE 13Other FEE <br /> INSPECTOR# J( / PERMIT VALID 1 15 to ,1Q 13 Food Handler <br /> 13Check# AmnoouN�TJPAIDF3j&a Date ;L INVOICE# Z <br /> ❑ Cash REVIEWEDBY /(,l//`� ACCOUNTING OFFICE Date /,l 02 <br /> 48-02-034 Masted,Record Pink <br /> 10/6/2003 <br />