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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD Ii 1FORitilATION FORNI(EH 00 69) <br /> ❑New EH Program and New Facility <br /> 1❑ New EH Pro am at Existing Facilitv <br /> Facility ID FA-2 DC 3 31�—) Proa ram Record ID <br /> Facility Address <br /> 2-05-1 E <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Square Footage Food Handlers Course required: Yes C1No C1 <br /> C3 Seating Capacityq ❑Vending Machines-Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑oPrepackaged Goods Only <br /> Vehicle Type Col <br /> ❑ Mobile Food Vehicle---Make License# Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> ❑ tivlobile Food Prep Unit--Make License# Sticker" <br /> Registration# to _0Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to C3Produce Stand <br /> ElSpecial Event - Dates of operation from <br /> DAIRY PROGRAM (2000 <br /> ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> 11 Grade A Dairy C1 Grade B Dairy <br /> CUPA ❑ St to Facility Surcharge(2399) <br /> RAZARD4US WASTE PROGRAM(2200) —_Tons Generated Per Year L S <br /> lHazardous waste Generator----------- <br /> ----- ❑ Conditionally Exempt(CE) <br /> Tiered Perm ❑ Permit-By-Rule Fixed Unit Permitting Facility ❑ Conditionally Authorized ❑ Permit- y- <br /> B Rule Household Hazardous Waste <br /> Unit <br /> 11 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 /> ❑ Jailor Exempt Institution Number of Units <br /> ❑ Hotel/iVlotel-------Number of Units Application Form <br /> Employee Housing(2700) Use Employee KousinzlLahor Camp App <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) UIC Site <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local CCRWQCB Cleanupnup Site ❑Sit PSSEP Cleanup Si <br /> ❑ Water Quality Remte ediation Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup <br /> RECREATIONAL HEALTH PROGRAM(3600) 0 Natural Bathing Area <br /> Number of Pools/Spas at Facility ClPool ❑ Spa(3600) C] out of Service Pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC a Body PiePROGRAM <br /> ing(4 M(4100) C1 Permanent Cosmetics(4122) <br /> C1 Tattooing(4121) <br /> LIQUID WASTE PROGRAM(4200) License Capacity Vehicle# <br /> # <br /> C3 Pumper Vehicle-Registration# ❑ Chemical Toilets Number of Units <br /> ❑ Pumper Yard [I Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) ❑ Ag/Cannery Waste Site ElSludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility <br /> ❑ Compost Facility ❑ Process/Recycle Facility ❑ Fa /Ranch Cleanup Site <br /> ❑ Refuse Vehicles-Number of Units_. El Dumpsters>20 cu yd—Number of Units � <br /> MEDICAL WASTE PROGRAM(4500) C3 C1 <br /> Generator ❑ Limited Hauler <br /> El Care El Acute Care ❑ Skilled Nursing C1 Large Generator - 10 C1 I 1 -60—❑>60 generators <br /> 11 Transfer Station ❑ Veterinary Clinic <br /> C] Common Storage Facility —❑ - <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS E 7006 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON ❑ Other FEE <br /> ❑Surcharge FEE <br /> PROGRA,m ELEMENT ZL� FEE 3 to /�3i/�3 _ [3 Food Handler <br /> �66gq PERMIT VALID Ol/D/ . / 09 0 o,S <br /> I,[SPFCrOR# 03 IVOICE# <br /> A,NIOUNT PaID Date <br /> ❑ Check# �� Date �i�/ tj/D . <br /> ❑ Cash REVIEWED BY ACCoLwnNG OFFICE ,int 99 <br /> Rev vi <br />