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N SAN JOAQUIN COUNTY ENVIROI`IAI'ENTA_t,HEALTH DEPARTMENT MASTERFILE RECORI)INFORMATION FORIA ❑New BH Program at Existia Facility E rogram and NetiS Facility Facilit •ID 1 l9, Pra ram Record IC� r� Facility Address <n �fi 1�v� (Please Check the appropriate description and specify size9 number of units and pertinent information.) FOOD PROGRAM(1600) F1 Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs® No ❑ ❑ Commissary ❑ Dry storage only El with Food Preparation ❑Vending 141aclaines–Number ofUnits El Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ElMobile Food Veliicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit–Make Vehicle Type 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) 11Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Muld-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑Hazardous Waste CFenerator..— Tons Generated Per Year ❑ Recycle f Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Perrait-lay-Rule Fixed Unit ❑Perrait-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST).(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B forms ROUSING PROGRAM(2400) ® Ilotei/lilotel Number of Units Dflail or Exempt Institution Number of Units E€ ptoym Housing(2700)Use Fmployee.djausinelfabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30'00) ❑ Environmental Assessment ❑ UST-CAI'Site F1 Local IBV Cleanup Site, ❑NPLJSEP Cleanup Site El UIC Site ❑ Abandoned IINV Site ❑ non-NPLJSEP Cleanup Site ❑RiWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P®ol ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) [I Poultry Farm Maximum number of bards ®Kennel TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Penuauent 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) WEl dfll ❑ 'Transfer Station ElAg/Cannery Wasteaste Site ® Sludge/Ash Site naste Tyre Facility ❑ Compost Facility ❑ Process(Recycle Facility 11CIA•I andfill Site El Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Manch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care 11 Acute Care ❑ Skilled Nursing ❑ Large Generator Cl Small Generator 11 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ I1-60--El >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVSFrfD 46-02-003 BlueAEEtica(ion Form I_MERGENCY NOTIFICATION FOR Tms FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph — PROGIZAMELEMENT tAn "1 V FEE ❑ Surcharge FEE ❑ OtlaerFEE _ TV4SPFCT0R#CSC PERMIT VALID to ❑ Food Handler 1.1 Check f� AmoU L T 11.6.11 _ bate ItIVOICEEl --fL 4CCOUNITING OFFICE _ ---— Date --- -- Cash f�IiVIE�'1F.UBY � 2 — — _-_ --°