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P-a- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> D New EH Program at Kjjs(� ty ONew EH Program and New Facility MAY 112012 <br /> lFacilitylD Pr® <br /> ETVIRONMENT HEALTH <br /> Facility Addres 13,2 5- 5� (,,f FN TtFP KRMITISERVICES <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:- YES 11 No 11 <br /> ElCommissary El Dry storage only D with Food Preparation 11 Vending Machines-Number of Units <br /> El Retail Market—Square footage with Meat Market only D Multiple Departments D Prepackaged Goods Only <br /> 0 Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 0 Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 0 Temporary Food Facility-----Dates of operation frown to 11 lee Plant <br /> D special Event -Dates of operation from to 11 Produce Stand <br /> DAIRY PROGRAM(2000) <br /> F1 Grade A Dairy D Grade R Dairy 11 Milk Dispenser—Number of Containers-in Multi-Head Unit <br /> CUPA D State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> D Hazardous Waste Generatorr:---Tons Generated Per Year 0 Recycle f Exempt System(2299) <br /> [I CRT Offsite Handlers(2219) 11 Silver Only(2222) [3 Appliance Recyclers(2217) <br /> Tiered Permitting Facility D Conditionally Authorized(CA) 0 Conditionally Exempt(CE) <br /> 0 Permit-Ey-Rule Fixed Unit 0 Permit-By-Rule,Household Hazardous Waste <br /> [I ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number ofAST <br /> UNDERGROUND STORAGE.TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> F1 Hotel/Motel—Number of Units E]jail or Exempt Institution,—Number of Units <br /> Employee Housing(2700)Use Employee,Iousing/fAbor Camp Appflca6on Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 0 UIC site <br /> D Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site. . D NPLJSEP Cleanup Site <br /> D Abandoned HHV Site 11 stun-NPL/SEP Cleanup Site D RNVQCB Cleanup Site '[3 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility D Pool 13 spa 1.1 Out of Service Poovspa D Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 0 Poultry Farm—Maximum number of birds D Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> 0 TattooLng(4121) 11 Body Piercing(4120) D rennauent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> E] Pumper Vehicle-Registration.# License# Capacity Vehicle ff <br /> D Pumper Yard 01'ackage Treatment Plaut. 11 Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) 11 Sludge/Ash Site <br /> • Landfill 11 Transfer Station 13 Ag I Cannery Waste Site <br /> •Waste Tire Facility 11 Compost Facility 11 Process[Recycle Facility 0 ClAiLandfill,Site <br /> D Refuse Vehicles-Number of Units 13 Dumpsfcrs>20 cu yd—Number of Units 0 Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 0Primary Care ' DAcute Care D Skilled'Nursing ❑Large Generator* Small Generator [ILimited Mauler <br /> 11 Transfer Station 11 Veterinary Clinic D Common Storage Facility--0 2-10—D 11-60--F1>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PHIS EITD 46-02-003 Blue Applicadort Form <br /> EMERGEWCY VO151CAT10R THIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON CCACV DayPh.Z09-2-q9-f106 Night Ph <br /> PROGRAM ELEMENT-4 Ito FEE El Surch D 0 er FEE <br /> INSPECTOR# PERMIT VALID t 0 ood Handler <br /> El Check# AMOUNT P ID Da e NVOICE <br /> ❑ Cash REVIEWER BY ACCOUNTING OFFIC Date <br />