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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM RECEIVED <br /> EN <br /> RECE <br /> ❑New EH Program at Existin Facility ew EH Pro and New Facility <br /> Facility ID O U t�( � 7 Pro ram Record lD P" S,a-(,,? FEB - 8 2007 <br /> Z , �T 'kC 7 SAN JOAQUIN COUNTY <br /> IFacility Address ENVIRONMENTAL <br /> (Please heck the appropriate description and specify Eim number of units and pertinent information.) HEALTH DEPARTMENT <br /> FOOD PROGRAM(1600) <br /> l Restaurant: Seating Capacity 0-57 Square Footage Food Handlers Course required:_ YES P�_ No❑ <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Maehines Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only <br /> ❑Mobile Food Vehicle—MakeVehicle 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(20W) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) f <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑CRT offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACH.rrY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Iiotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Rousing(2700)Use pmployee Housing bor Camp Applicadon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLJSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ElPoultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑Body Piercing(4120) ❑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 /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑CIALandfill Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Stalled Nursing ❑Large Generator 11 Small Generator ❑Limited hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----❑2-10 ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON u�2 io�`�r e— Day Ph "� (o S i Night Ph <br /> Z ��i <br /> PROGRAM ELEMENT �� FEE 2-2—C' F _ ❑ Surc�hlarge�FEE •• e ❑ Other FEE <br /> INSPECTOR# /(�9 PERMIT VALID o % to o� oC l O D ❑Food HandlerJ �j <br /> JEJ Check# \ AMOUNT PAID a (� Date I t INVOICE# r 5147 0 �_ <br /> ❑ Cash REVIEWED BY 6-0 032_- ACCOUNTING OFFICE Date 7 <br />