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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORIA <br />❑ New EH Program at Existing Facility 6]New El Program and New Facility <br />Facility ID A" fid' ,112 S5 ` Pro ram Record ID ` <br />Facility Address . 910 N ' &-V–ml watA Lt. 0A 0A a (�} is SOS <br />(Please Check the appropriate description and specify sizenumber of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />[I Restaurant: Seating Capacity Square Footage Food handlers Course required: Yes ❑ No 11 <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑\'ending Machines –Number of Units <br />❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit–Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility—Dates of operation from <br />❑ Special Event –Dates of operation from <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (20W) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Bead Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />IIAZARDOUS WASTE PROGRAM (2200) d <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 ❑ Pernut-By-Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B (arms <br />HOUSING PROGRAM (2400) <br />❑ notenIotel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee housing (2700) Use Fmploree ffousinglLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(30W) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local IPV Cleanup Site. ❑ NPLfSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned IIW Site ❑ aou-NPLISEP 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 />❑ Poultry 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 />Ek Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle 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 />ElPrimary Care 1:1 Acute Care ❑ Skilled Nursing 11 Large Generator ❑ Small Generator ❑ Limited hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --El 2 - 10 ❑ 11 - 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PH SEFID 46-02-003 Blue Applica(iorn Form <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />Day Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE <br />INSPECTOR# ��7,Z PERMITVALID to <br />❑ C icck i <br />❑ Cash <br />AMOUNT PAID <br />REVIEWED BY 5' 11 <br />Night Ph <br />❑ Other FEE <br />❑ Food Handler <br />Date INVOICE # <br />ACCOUNTING OFFICE Date <br />