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SAN JOAQUIN COUNTY ENerRONMENTAL HEALTH DEPARI,,0.NT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ED F140 n 159Dla Program Record ID - jr)35 Facility Address 233/3 e &Qni46 bn,a.t (Please Check the appropriate description and specify size,number of units and Dertineitt information.) FOOD PROGRAM(1600) ❑Restaurant: - Seating Capacity --Square Footage Food Handlers Course required:--YES❑--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 CUPA ❑ State F cility Surcharge(2399 Z'L 26 HAZA S WASTE PROGRA (2200) Hazardous Waste Generator------------Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance 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 Ereplovee Housing/Labor 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) Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm--Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM 4200) E3 Pumper Vehicle--Registration# License# Capacity 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/Ranch 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-----❑ 2-10-------❑ 11 -60—----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EMD 4602-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON �dt Day Ph Night Ph PROGRAM ELEMENT T 70 FEE r'qC& —_ [:] SurchargeFEE a�f.UD ❑ Other FEE INSPECTOR# aJ (! PERMIT VALID I / D S to ❑ Food Handler ❑Check# AMOUNTPAID Date INVOICE# 13D4,S`Z ❑ Cash REVIEWED BY /ACCODNTiNGOFFICE Date '/3 ps 48-02-034 1. 07 Masterfile Record Pink 10/62003 -