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SAN JOAQUIN COUNTY V --'IRONMENTAL HEALTH DIVISI' N MASTERFILE RECORu INFORMATION FORM (EH 00 69)PAYMENT RECEIVED ❑ New EH Program at Existing Facility ❑,New EH Pro ram and New Facility Facility ID Ji'f 7 Co Program Record ID MAR 4 2003 Facility Address 2$ 4 Gita f L i - Rte I rq c SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (Please Check the appropriate description and specify size, number of units and pertinent information.) ENVIRONMENTAL HEALTH DIVISION FOOD PROGRAM (1600) �Rstaurant: Seating Capacity �J I + Square Footage Food Handlers Course required: YES ❑ 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 ❑ 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 ❑ Siate Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator ----------Tons Generated Per Year ❑ Recycle / Exempt System 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 LISTA and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution ------Number of Units Employee Housing (2700) Use Employee HousitmlLabor 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 TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --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 ❑ 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 ----- ❑ 2 - 10 ------- ❑ 1 1 - 60 ------ El > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form EMkRGENCY NOT1,171CA1,10N FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON-- _ -- Day Ph Night Ph PROGRAM ELEMENT �(J [��, _ FEE ��V ❑ Surcharge FEE ❑ Other FEE INSPECTOR #LQ—I i`—P'E`R-MIT VALID 3M)4?'3 to ElFood Handler Check # / AMOUNT PPA�IQD,� t2 o2y Date INVOICE # /P ElCash RL-mEwED nY l J (i..1 1 1101X7 f , ,. ACCOUNTING OFFICE A nom— Date f) .�f / 1:110061) Pink Perm Rev. 02/25/03