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SAN JOAQUIN COUNTY ENV ONMENTAL HEALTH DEPART +NT MASTERFILE RD INFORMATION FORM ❑New EH Program at ExistingFacilit New E1-1 P-- rn and New Facility Facility ID Program Record Ill 5-ga/S Facility Address 4iQ2 (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Foolage — - - ..__.._. Hood Ilandlers Course rCguil'Cd: VIZS❑ NO ❑ ❑ Commissary ❑ Dry storage only ❑ with I,00d 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 It License It Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration It 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 Generato►--------------Pons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Ilandlcrs (2218) ❑ SiIVCI.Only(2222) ❑ Appliance Rccyclers(2217) Tiered Permitting Facility------------------ ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-lay-Rule Fixed Unit ❑ Permit-lay-Rule IIousehold hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM(2400) ❑ Ilotcl/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee(lousing(2700) Ure Employee//ousin�/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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ 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) ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# ElPumper Yard ElPackage Treatment Plant ❑ Chemical Toilets-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Units ❑ Dumpstcrs>20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----112- 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_ 4-�7l-(-CJ FEE ❑ Surcharge FEE ElOther FEE INSPECTOR# L4'6 S PERMIT VALID /Q �( 0 to to 6/Q El Food Handler El Check# AMOUNT PAID -p Date INVOICE-# ❑ Cash REVIEWED BY ACCOUNTING OFFICE / i Date 4f Zf p 48-02-034 Masterfile Record Pink 11/18/03