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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD-INFORMATION FORM RECEIVED EN RECE ❑New EH Program at Existing Facility ew EH ProgM and New Facility P FacilityH) OU ►��,�Z 7 ` Program Record ID " FEB - 8 2007 Sa 1,�810 Facility Address Z i bk) �hrL�, L"`�E I -7 c C 7 SAENVIIRONM NN JOAQUIN OTAL (Please Check the appropriate description and specify siz number of units and pertinent information.) HEALTH DEPARTMENT FOOD PROGRAM(1600) l Restaurant: Seating Capacity �-� Square Footage Food Handlers Course required:_ YES P�_ No❑ ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Maehines 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 Veliicle Type Color Registration# License# Sticker# ❑Temporary Food Facility---.Dates of operation from to 11 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) t ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(2217) 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(USI)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑Ilotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Fmployee HousinglLabor Camp Applicadon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local 11W Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site 1❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR.CONTROL PROGRAM(4000) [3Poultry Farm Maximum number of birds 11 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑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/Raacb Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Stalled Nursing ❑Large Generator 11 Small Generator ❑Limited hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----❑2-10 ❑ 11-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PN'SEIfD46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR Tms FACILITY AND/OR PROGRAM CONTACT PERSONS u u IG2 i�1 '{o�`�r Day Ph "�-- (v�S i Night Ph Z �i PROGRAM ELEMENT �� FEE 2-20 r ❑ Surc�hlarge�FEE •• e ❑ Other FEE INSPECTOR# /(o PERMIT VALID o % to o� oC l O D ❑Food Handler�iG, Check# \ AMOUNT PAID a 6D Date D I INVOICE# 6 Cash REVIEWED BY 6-003Z- ACCOUNTING OFFICE �,� Date 7