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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPAR ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility New EH Pro am and New Facility PAYMENT <br /> Facilit H) t7 Pro ram Record ID <br /> RECEIVED <br /> Facility Address 1 (0 2`( E - A L_,4,,` A-L;`E S 71�- ") AUG 18 2005 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) SAN ENVIROOAQUINNMENTAL NTAL <br /> ENVIRONMENT,tAELH1� <br /> ❑Restaurant: Seating Capacity Square Footage -- -- -Food Handlers Course T "M O 1:1- - <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑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 ❑ 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 /> CUPA ❑ State Facility Surcharge 2399 <br /> HAZ OC US WASTE PROGRAM(2200) <br /> Hazardous Waste Generator---- ------Ton Generated Per Year `S ❑ 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(270)U <br /> GATION(2 Use Employee Housiue/Labor Camp Application Form <br /> . SITE MITI0) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Enviromental Assess ent CI UST-CAP Site 11 Local HW Cleanup Site ❑ NPL/SEP Cleanup Site 11UIC Site <br /> ElAbandon HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATION HEAL PROGRAM(3600) <br /> Number of Pools/Spas tty ❑ 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(4100) <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 - ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site Cl 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) J <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler - <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----112- 10-------1111 -60-----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIYS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELENIENT 2Z2O FEE it ZxO `� ❑ Surchar ee FE 11Other FEE <br /> INNSPECTOR# r0 3 13 PERMIT VALID to c7 ❑Food Handler <br /> IXCheck# /,_J �� - AMOUNT PAID txp Date INVOICE# )34 _ <br /> 11Cash REVIEWED BY &0 ACCOUNTING OFFICE Date <br /> 48-02-034 Masterfile Record Pink - <br /> 10/612003 <br />