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SAN JOAQUIN COUNTY ENIWONMENTAL HEALTH DEPAR' <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ❑New EH Program and New Facilit <br />Facility ID CFi- Uv (8U v 1 Program Record ID Y' A-0 <br />Facility Address 3 3o A v_gt orJ Ave- FZCel TragwiofiD)i— <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) --eM Z:tr <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 Food Vehicle -----Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit -Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility ----- Dates of operation from to <br />❑ Special Event --Dates of operation from to <br />Color <br />Sticker # <br />Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser --Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />F-1 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 ------------------ El 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 USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/;Motel-------Number of Units ❑ Jail or Exempt Institution -------Number of Units <br />Employee flousing (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 <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets ------Number of Units <br />❑ Landfill <br />❑ Transfer Station <br />❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />$d Waste Tire Facility <br />❑ Compost Facility <br />❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number <br />of Units <br />❑ Dumpsters > 20 cu yd ----Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care <br />❑ Acute Care ❑ Skilled <br />Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station <br />❑ Veterinary Clinic <br />❑ Common Storage Facility ---- C1 2 - 10------- <br />❑ 11 - 60------❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PUS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day Ph Night Ph <br />PROGRAM ELEMENT �'f ii() FEE _ <br />INSPECTOR # ooh 0 PERMIT VALID <br />❑ Check # <br />❑ Cash <br />48-02-034 <br />10/6/2003 <br />ANIOUNT PAID <br />REVIEWED BY 3_F (01.0m) <br />❑ Surcharge FEE <br />to <br />Date <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # <br />,ACCOUNTING OFFICE � � Date <br />Masterfile Record Pink <br />