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SAN JOAQUIN COUNTY EN ONivIENTAL HEALTH DEPART ' INIASTERFILE RECORD INFORNIATION FORAT New EH Program at Existing Facility ❑New EH Program and Nf-- Facility ID FA 001 &00( Program Record Facility Address Mo W, IVO VY p (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes 11 No El ❑ 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# License= Sticker# ❑ Mobile Food Prep Unit-Make Vehicle T%Fe Color Registration# License= Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE.PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ 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) Nu;nber of AST UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use CSTAand B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee Ilousing(2700) Use Employee floysinglLahor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ l'ST-CAP Site ❑ Local HNN Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN QCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Nuher of Pools/Spas at Facility 11Pool ElSpa ❑ Out of Service Pool/Spa El Natural Bathing Area m VECTOR CONTROL PROGRAM(4000) El Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM 14100, ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle -Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM(4400) El Landfill El Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site 1:41NVaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Reruse Vehicles--Numher of U11its ❑ Dumpstcrs>20 cu yd----Number of Units ❑ 1,arm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) 11 Primary Care El Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generator El Limited Hauler C1 Transfer Station El Veterinary Clinic 11 Common Storage Facility----112- 10------- El1 1 -60--- El >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PIPS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT `+-lt-I'D FEE ❑ Surcharge FEE ❑ Other FEE INSPEC'roli# 00G20 Pf:RN41r VALID to ❑ Food Handler ❑ Check# ANIO INT PAID Date INVOICE# 11 Cash REVIEWED D1' M I I S L ACCOUNTING OFFICE Date 1 N sterfile Record Pink 38-02-033 10,'6/2003