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---------------- <br /> SAN JOA QUIN COUNTY E RONMENTAL HEALTH DEPARIN..BENT F , <br /> MASTERFILE RECORD INFORrTATION FOILYI <br /> 'New EH Program at ExistingFacility - <br /> ❑New EH Pro and New Facili <br /> Facilit IDAni TliLl Program RecordID <br /> Facility Address 5 5='[' — r'"3 Q h — <br /> (Please Check the appropriate description and specify size,number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) - <br /> - Square Foofage Food Handlers Course required:—YES❑ No ❑---- <br /> ❑Restaurant: Seating Capacity q ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation <br /> ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments 11 Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle----Make License" Sticker# <br /> Registration# Vehicle Type Sticker# <br /> Color <br /> ❑ Mobile Food Prep Make <br /> Registration# License"� to ❑ Ice Plant <br /> ❑Temporary Food Facility-----Dates of operation from ❑ produce Stand <br /> ❑ Special Event --Dates of operation from <br /> to <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade B Dairy [3 AlilitDispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) ❑ Recycle I Exempt System(2299) <br /> IKHazardous Waste Generator------------Tons Generated Per Year ❑ Appliance Recyclers (2217) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2___) <br /> Tiered Permitting Facility <br /> ❑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 (2400) <br /> El jail or Exempt Institution—Number of Units <br /> ❑'Hotel/Motel-------Number of Units <br /> Emplolee /Labor Cama Application <br /> Employee Housing(2700)Use Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ite ❑ <br /> IC site <br /> 11 Environmental Assessment ❑UST-CA <br /> LpS it Cleanup Ste Local HW Cleanup <br /> R"QCB CleanupSitepL/s ❑ <br /> ❑ Water Quality Remediation Site <br /> El Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service PooUSpa ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds . <br /> TATTOO 80DY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ permanent Cosmetics(4122) <br /> ❑Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# <br /> [:] Pumper Vehicle--Registration#� <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets-----Number of Units <br /> SOLID WASTE PROGRAM(4400) 0 Sludge/Ash Site <br /> ❑ Landfill <br /> ❑Transfer Station ❑ ProcesslRecycle Facility❑ Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> E3 Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number of Units El Dumpsters>20 cu yd---Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler- <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑>60 enerators <br /> ❑Transfer Station ❑ Veterinary Clinic <br /> [j Common Storage Facility-_0 2-10--'❑ 1 I -60---- g <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Forret <br /> EME13GENCY NOTIFICATION FORTHIS FACILITY AND/OR PROGRAM <br /> ' `bay Ph _�� Night Ph <br /> CONTACT PERSON ❑ Other FEE--- <br /> G <br /> FEE UFO UU ❑ Surch rge FEE ❑ Food Handler <br /> ESPER# <br /> LEMENT 7 Z ZD topEfr VALID REVIEWED BY ACCOUNTING OFFlCE ' <br /> Muterfile Record Pink <br /> 48-02-034 <br />