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SAN JOAQU1N COUNTY L'f,11tUNMLNTAL 1-1EAL'1'll DEI'AI#IEN'1' <br />MASTERFIL 'AK CORD INFORMATION FORM <br />New EH Pro ram at Existing Facility❑New EH Program and New Facilit <br />FacilityID >"� U `��6 6�' Program Record Ill <br />Facility Address fib?, �'4a_eo 6,e )2& <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 ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending 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 Color <br />Registration it License it Sticker # <br />❑ Mobile Food Prep Unit --Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility -----Dates of operation from to <br />❑ Special Event --Dates of operation from to <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (22 18) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility----------------- ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -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 forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution -------Number of Units <br />Employee Housing (2700) Use Employee HousinglLabor Caron Application Forin <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />11Environmental Assessment ElUST-CAPSite 1jLocal IIW Cleanup Site ❑ NPL/SEI' Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Ounlity RPmP.Ii.t1 .. c:te <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Milk Dispenser ---Number of Containers in Multi -Bead Unit <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm --Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration # _ <br />❑ Pumper Yard <br />License It <br />❑ Package Treatment Plant <br />❑ Natural Bathing Area <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets -------Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care <br />❑ Transfer Station ❑ Veterinary Clinic <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Common Storage Facility ----- 112- 10 ------- ❑ 11 -60 ------❑ > 60 eeneratnrc <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Forni <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Dav Ph Ni"l.t al, <br />PROGRAM ELEMENT 4'0 FEE _ <br />INSPECTOR# PERMIT VALID <br />❑ Check # AMOUNT PAID <br />❑ Cash REv1EWEDBY <br />❑ Surcharge FEE ❑ Other FEE <br />m <br />Date <br />ACCOUNTING OFFICE <br />❑ Food Handler <br />INVOICE # <br />Date I/.;;?7/0 <br />48-02-034 <br />11/18/03 <br />Masterfile Record Pink <br />