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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION MASTERFILE RECORD INFORMATION FORM EH 00 69 ❑ New EH Program at Existing Facility ❑New EH Pro ram and New Facilit Facility ID r---A-o d 1 3 Program Record ID Pao S `1 Z Facility Address 188�5 0'44-' fr r,-2�t r� C(.} (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No ❑ ❑ Conuni a ❑ Dry storage only 13 with Food Preparation ❑Vending Machines--Number of Units Retail !�--Squarc footage ; ❑ with Meat Market only ❑ Multiple Departments A Prepackaged Goods Only Mobile Food Vehicle-----Make Vehicle Type Color Registration It License it Sticker ll ❑ 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) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ IIazardous Waste Generator-----------------------Tons Generated Per Year 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 UST A and B forixs HOUSING PROGRAM(2400) ❑ I-lotel/Motel-------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee/fo«sinr/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local IiW Cleanup Site ❑ NPL/SEP Clcanup Site ❑ UIC Site ❑ Abandoned IIW 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(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vchicic--Registration# License# Capacity Vehicle# .- ❑ Pumper Yard ❑ Package 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 ❑ Dumpsters>20 cu yd----Number of Units ❑ Farnt/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 ----El 2- 10-------❑ 11 -60------1:1 >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACT TY AND/OR PROGRAM CONTACT PERSON '(2 Day Ph 0 Night Plt yy PItOCRAM ELEMENT )(,f 17 FEE ZOb, Gy ❑ Surcharge FEE 2 Other FEE .2-00-0,0 lNsrrcrott# �')3 l0 I p PERMIT VALID 'oh�,200 `to �J/►� 30f DD /-❑ Food Handler hcck# Z 9 d 9 0 AMOUNT PAIll O Date�1,3 6 J D3 �-Z2r4NVOICC/I //:� Cash REVIEWED BY K (30 o'`j ACCOUNTING OFFICE —; /' D a t c Date —3a _ o L•f t(j"169 PINK FOKM.doc dlL I, 9 _ �.�A-(,ZeY �E Rcv.07/07/99 n w�`