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SAN JOAQUIN COUNTY E ONMENTAL HkALTH DEPARilys T MASTERFILE RECORD INFORMATION FORM ViNew EH Program atatlExistin Facility ❑New EH Program and New Facility FacilityH) rl� a� 1=S1, Program Record I1) ko 9.;-q"-7 Facility Address 2`53 5� Ca''t-t L_ d *o - (Please Check the appropriate description and specify size•number of units and pertinent Information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ No❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-Number of Units ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event -Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit CU PA ❑ State Facility Surcharge(2399) HAORDOUS WASTE PROGRAM(2200) azardous Waste Generator----------Tons Generated Per Year < S TOA 113Recycle/Exempt System(2299) 11 CRT Offsite Handlers(2218) ❑ Silver Only(2222) ppliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel---Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee HousinelLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UiC Site ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) ��,,aa,,//�� -1 Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ OU*dlp ej pa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds 5 2005 ❑ Kennel TATTOO,BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) O1-T ❑ Tattooing(4121) ❑ Body Piercing(4120) ou%14 manent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) SAN RONM RTMEt'tT ` LTH DEPA 11 Pumper Vehicle--Registration# License# H`t:apacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Raoch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---13 2-10--❑ 11 -60—❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form ENCY OTIFIC TION FOR THIS FACILITY AND/OR PROGRAM �r X CONTACT PERSON T Day Ph 2D9–%3 t—e-oo'TNight Ph 2-0`1 ' PROGRAM ELEMENT�L0 FEE -� ❑ Surcha FEE [3Other FEE INSPECTOR# .SS PERMIT VALID CS t i Food Handler 17cheek# 1O Z AMOUNT PAID D Date Z S D INVOICE# /3'16/ ❑ Cash REviEwED BY AccoUNTING OFFICE Date 3' ('0 48-02-034 Masterfile Record Pink 10/6/2003