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SAN JOAQUIN COUNTY EONMI NTAL HEALTH DEI'Al <br /> y MASTERFILaRD INFORMATION FORM <br /> -MiNcw EH Pro ram at Existing Facilit ❑New EH Pro ram and New Facilit <br /> Facilit ID A_0t70 9Z3 Program Record Ill <br /> Facility Address 3Z,-0► I-)t tc-n,< � , S ew cA ai 52-15- <br /> (Please <br /> 2-1S(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 hood Vehicle-----Make „ Vehicle Type ._-_-.. Color <br /> Itegislruliun 11 _ -- --- ----- ----- License 11 ---- _— - Slicker 11 <br /> ❑ Mobile Food Prep Unit--Make Vchicic'I'ype - - Color <br /> Registration Il License 11 Sticker 11 <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-licad Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ 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 of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application 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 ❑ Package Treatment Plant ❑ 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 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) ENVIRONMENTAL HEALTH <br /> 11 Primary Care 11 Acute Care El Skilled Nursing ❑ Large Generator DEPARTMENT NO LONGER <br /> ❑ Transfer Station 11 Veterinary Clinic El Common Storage Facility-----❑ 2' INSPECTS WASTE TIRE <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PlYS EHD 46-02-003 Blue Application Fd <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/(, FACILITIES. It is a State run <br /> CON rnC't'PERSON Day Ph grogram effective 7/1/2017. <br /> PROGRAM ELEMENT L f'� T� FEF, 11 SurchargeFEE 1:1 Other FEE <br /> INSPECTOR# 'C6_3 PERMII'VALID "1(I(0 to /3o�os' ❑ Food Handler <br /> ❑ Check H AMOUNT PAID �O= Date INVOICE#E <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date D <br /> 4M2-034 Masterfile Record Pink <br /> 11/18/03 <br />