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SAN JOAQUIN COUNTY E. 4RONMENTAL HEALTH DEPAF LENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH Pro am at Existing Facility ❑New EH Pro am and New Facili <br /> ty <br /> Facili ID LJ Program Record ID Q 7 <br /> Facility Address 2'11_ U SMO\Q CD 0 C,11 12G� �t C C�c j X17 <br /> (Please Check the appropriate description and specify size"number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No❑ <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 ❑ Produces <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUP A ❑ State Facility Surcharge(2399) ., <br /> HAZARDOUS WASTE PROGRAM(2200) - <br /> ` Hazardous Waste Generator------------Tons Generated Per Year C fD 13 Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221 s) ❑ 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 Number of Units <br /> Employee Housing(2700)Use Employee Housine/Labor Camp AnpGcation Form _ <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) " <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ 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(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration#, License# Capacity Vehicle# <br /> ❑ Pumper Yard I ❑ Package Treatment Plant 11 <br /> Chemical Toilets------Number of Units - <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 to yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) - <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON hAj V h. Day Ph (2p�g4b-q h-A Night Ph <br /> PROGRAM ELEMENT 2220FEE 3 ❑ Surchar FEE 11Other FEE <br /> INSPECTOR# 1 L}91 — PERMIT VALID / ( to 91 02 ❑ Food Handier <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY I ,DD v ACCOUNTING OFFICE Date (� <br /> 48-02-034 asterfile Record <br /> 10/6/2003 - <br />