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f <br /> r <br /> • <br /> SAN JOAQUIN COUNTY ENVIRONA.I.ENTAL HEALTH DLPARTn2LNT <br /> MASTERFILE RECORD INFOrOIATION FORM <br /> ❑New EH Program at Existaag Facility ew EH Program and New facility_ <br /> Factlif ID rkD Cb2IOy-I Pro ram Record ID �z 53��D <br /> Facility Address X8 �u Ave- MG J e,ux, A S <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YI:s❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation 11 Vending Mnhines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Dead Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator.— Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By Rule Fixed Unit ❑ Permit-lay-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST),(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B forms <br /> ROUSING PROGRAM(2400) <br /> ❑ Rotet/blotel Number of Units -❑.Tail or Exempt Institution Number of Units <br /> Eaaployee Ifousicag(2700)Use Fmpla yee IfaasinKgbor Camp Applicadarr Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑Local IBV Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IBV Site ❑ rioa-NPLISEP Cleanup Site ❑RNVQCB Cleanup Site ❑bVater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. El Pool ❑ Spa ® Out of Service Pool/Spa ❑ Natural Bathing Area <br /> ®LECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4109) <br /> ❑ Tattooing(4121) ❑Body Piercing(4 120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ® Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> f WWaste Tare Facility ❑ Compost Facility ❑Proces3fRecycle Facility ❑ CIA-Landfill Site <br /> Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator 0 Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2- 10 ❑ I1-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PJVSEFfD f6-02-003 BlueApp(ica(ion Fornr <br /> FNIEZGENCY NOTIFICATION FOR THIs FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> I'RocaumELEMEN1T_ 3 _ FEE ❑ SurchargeFeE ❑ Other FEE — <br /> INSPF_CTOR# L� PERMITVALID__--_ to El Food Handler__ <br /> CJ check f,`- Ai\iouI rr 1'h.tv %Date 11 VOICE# <br /> —❑ Cash I:SVIFVIED BY`t7�— /b/29/4 AccoLTC,mi,,(i OFFICE Date <br />