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1 e SAN JOAQUIN COUNTY E. ONMENTAL HEALTH DEPAR NT NIASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ONew EH Program and New Facility Facilit ID d 101 1-1S-L)L Program Record ID �S9-1{ Facility Address - ` OQOI —6 jf4cL I1-irlley (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capaciq Square Footage Food Handlers Course required: 2'Es El No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration r License# Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration" License# Sticker# El Temporary Food Facility-----Dates of operation from to El Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) El Grade A Dairy El Grade B Dairy El Milk Dispenser--Number of Containers in Multi Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE.PROGRANI (2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2213) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility------------------El 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 LISTA and B forms HOUSING PROGRAM(2.100) [I Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee llousing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HNN'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number ol'Pool `Spits at Facility 1:1 Pool El Spa El Out of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm -------- El Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) El Tattooing(4 12 1) 11 Body Piercing(4120) El Permanent Cosmetics(d 122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM(4400) 11 Landfill El Transfer Station El Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste"fire 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) El Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10------- ❑ 11 -60--- - ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 BlueApplieation Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 4� q FEE ❑ Surcharge FEE ❑ Other FEE INSI'1?C"fog# 00co O PERMIT VALID to --- ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED av T(Z to G� pS ACCOUNTING OFFICE � Date Masterfile Record Pink d8-02-03-4 10/6/2003