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SAN JOAQUIN COUNTY ENV NMENTAL HEALTH DEPARTNOT MASTERFILE RECORD INFORMATION FORM New E[I Program at Existing Facility ❑New EH Pro ram and New Facilit Facilit ID r—{k D C)/ ("(O 2 Program Record ID j,A-0 s- 9�S Facility Address 79 S E • 9 ko( # L (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) F-1 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 13 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# License# Sticker# ❑ Mobile Food Prep Unit -Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to El Ice Plant ❑ Special Event --Dates of operation from to El Produce Stand DAIRY PROGRAM (2000) El Grade A Dairy El Grade B Dairy 11 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------------------❑ 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 USTA and B forms HOUSING PROGRAM(2400) ❑ C1 Hotel/Motel-------Number of Units Jail or Exempt Institution-------Number of Units Employee Housing(2700) Use Employee HousinQ/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility El Pool 11 Spa El Out of Service Pool/Spa ❑ Natural Bathing Arca VECTOR CONTROL PROGRAM(4000) El Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ "Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) El 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 13 Ag/Cannery Waste Site ❑ Sludge/Asti Site 'Waste Tire 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) ❑ Primary Care 1:1 Acute Care C1 Skilled Nursing El Large Generator El Small Generator ❑ Limited}Iauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 02- 10- 10------- ❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT V `�C FEE El Surcharge FEE 11 Other FEE INSPECTOR# ��'C> / PERMIT VALID to 11 Food Handler ❑ Check 4 AMOUNT PAID Date INVOICE# ❑ Cash REVIEWEDBY .T.ellctit_ L ACCOUNTING OFFICE %L. Date 48-02-034 ,5 Masterfile Record Pink In/6nn01 �''',��G.t c✓A7�'