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SAN JOAQUIN COUNTY ENVIRONnZENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility El New EH Program and New Facility <br /> Facilif ID Pro ram Record ID ,.3 <br /> Facility Address l2ev 14"t so» =— <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YES 11 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 /> El Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker <br /> 11 Mobile Food Prep Unit—Make Vehicle Type Coll <br /> or <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to El ice Plant <br /> 11Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(20110) <br /> ❑ Grade A Dairy, ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' a <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 USIA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/lliotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Fmployee HousfftK bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IBB Site ❑ non-NPL;SEP Cleanup Site ❑RWQCB Cleanup Site T❑`Vater Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3604) <br /> Number of Pools/Spas at Facility. ❑Pool 11 spa <br /> ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ElPumperNehicle—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 ❑ Dumpsfers>20 cu yd—Number of Units ❑ FarrnlRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) ENVIRONMENTAL HEALTH <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator DEPARTMENT NO LONGER <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---❑ 2 J <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePff'SEHD 46-02-003 Blue Applica(ion Fo� INSPECTS WASTE TIRE <br /> FACILITIES. It is a State run <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OF program effective 7/1/2017. <br /> CONTACT PERSON_ Day Ph t _ <br /> — - i <br /> PROGR4AtELEN1ENT___C4q-_(4 0 FEE a ❑ Surcharge FEE '" ❑ Other FEE _ <br /> INSPECTOR4 - _ PEI;MIT VALID (2' _ to ❑ Food Handler_. <br /> El Chcck t, .F moul rr 1'kw _ Date ltrVOICE# __-- <br /> ❑ CashFLEIVIFWED BY -- ACCOVNTl1dG OFFICE — _ _ Date <br />