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N � D SAN JOAQUIN C OUN-1 4VI RON1dIEN IAl I-ILAL1Jl IJLI'A*,ILN'I' AUG 11 2010 MASTERFILE RECORD INFORMATION FORM ew EH Program at ExistingFacili i�,, Ie'�01V11IIFI'`]T I ICA fI ❑New EH Program and New Facility !-.Mili'� '!%1Ci S Facilit ID ?j Program Record ID 5 Fatality Address E P? --, I r-Ive- (Please Check the appropriate description and specify size.number of units and pertinent info ation.) 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 Cl Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑Prepackaged Goods Only 11Mobile 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 Cl Produce Stand DAIRY PROGRAM(2000) 11 Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUP A ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ,Hazardous Waste Generator------------Tons Generated Per Year -e E5 ❑ Recycle/Exempt System(2299) 13CRT Offsite Handlers(2218) 11Silver 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 USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑Jail or Exempt Institution-----Number of Units Employee Housing(2700)Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NAL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) i 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(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ 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-------011 -60------❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PFVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON M Day Ph zo9-7S6—7((3 Night Ph PROGRAM ELEMENT 227-p FEE fZ3,C0 ❑ Surcharge FEE ❑ Other FEE INSPECTOR# _ PERMIT VALID ''--�� to ❑ Food Hanrdier ®check k ,��!j,�j AMOUNT PAID Date 1� INVOICE// �C 5 3 Z6 ❑ Cash REVIEWED BY C) ?j ACCOUNTING OFFICE Date [; 48=02-034 PAYMENT Masterfile Record Pink 11/18/03 RECEIVED AUG 1 1 2010 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT