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SAN JOAQUIN COUNTY EN IRONMENTAL HEALTH DEPARTMENT MASTERFILE Rll INFORMATION FORM f� ew EH Pro ram at Existing Facility ❑Ncw EI-I Pro ram and New Facilit Facility ID Pro ram Record ID 6 d Facility Address es <:::G,Q o14.9— L t., (Please Check the appropriate description and specify size,number of units and pertinent information.) l� r FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: VEs ❑ 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 Vchicle Type Color Registration It License# Sticker tl ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenscr---Nunlbcr of Containers in Multi-I lead Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers (2218) ❑ Silvcr Only(2222) ❑ Appliance Recyclers(2217) Tiered Perinilting Facility------------------ ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) 1Permit-By-Rule Fixed Unit El Permit-By-Rule Ilousehold Ilazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST UNDERGROUND STORAGE TANK(UST) PROGRAM(2300) Use IIST A and B(orris HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee Ilousing(2700) Use Employee Ilousing/Lahor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local IIW 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# License It 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/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Ilauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PNS EHD 46-02-003 Blue Application Faint EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 4_7q-0 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# G _ PERMIT VALID to ❑ Food Handler ❑ Check It —t AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE. Date 3156 1 CS- 49-02-034 Masterfile Record Pink 11/18/03