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SAN JOAQUIN COUNTY 1{:I�IZONMII,N'1'Al, HEALT11 DETARJ;1I�,NT MASTF,1211'11 X 'ORI) INFORMATION FORM LlS Ncw LI I Program al Existing Il ❑New Id I Pro gram and New Facilit Facility ID r- C t7 D 3-7 OP Program Record Ill 0 Rz S2'-.�L-5-0 Facility Address '--?49 (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity 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 It License It Sticker# ❑ Mobile Food Prep Unit--Make Vchicic Type _ _ Color Regishation 11 _ License 11 Slicker It ❑ "Temporary Food Facilily-----Dates ofoperalion Iruin--_ _ -----_._---- -._._. to — ❑ Ice Plant ❑ Special Event --Dales ofoperation Irum _ _ —__ to ❑ Produce Stand DAIRY PROGRAM(2000) El Grade A Dalry ❑ Grade 11 Dairy ❑ Milk Dispenser---Numbcr of Containers in Multi-I lead Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Ilazardous Waste Generator-----------=Pons Uencrated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Oflsitc I landlcrs (2218) ❑ SiIVCI'Only(2222) ❑ Appliance Rceyclers (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(UST)PROGRAM(2300)Use UST A and B(orins HOUSING PROGRAM(2400) ❑ HoteUMotel-------Number of Units ❑ Jail or Exempt Institution-----Number of Units Employee Housing(2700)Use Employee Housing/Labor Camp Application Forst 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 ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration It License II Capacity Vehicle# ElPumper Yard IJPackage 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-----112- 10-------011 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Forst EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON // Day Ph Night Ph PROGRAM ELLEMENT 7 4-1-0 FEE ❑ Surcharge FrH: ❑ Other FEE INSPECTOR# L4-t- (n PERMIT VALID `Z t 0 q to 4-1'31)(09 ❑ Food Handler ❑ Check It AMOUNT PAID Date INVOICE it ElCash REVIEWED BY ACCOUNTING OFFICE '/zv[ Date 7.1 0 48-02-034 Masterfile Record Pink 11/18/03