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tw SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPAR NT ` MASTERFILE RECORD INFORMATION FORM ` New EH Proeram at Existing Facility ❑New EHPro ram and New Facilitv Facilit ID A C/ Program Record ID Facility Address , �G C� -hh I S i� lc�� n� to, (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 11Retail Market----Square footage 11with Meat Market only ElMultiple Departments El Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit -take Vehicle Type Color Registration# License# Sticker# El Temporary Food Facility-----Dates of operation from to El Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser --Number of Containers in Multi-Head 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) ❑ Silver Only (2222) ❑ Appliance Recyclers (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 USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Numbcr of Units ❑ Jail or Exempt Institution-------Number of Units Employee llou,ing(2700) Use Employee HousinzlLahor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) NUmbcr of Pools/Spas at Facility Cl Pool El Spa El of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm -------Maximum number of birds El Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) 1:1Tattooing(412 1) C3 Body Piercing(4120) 1:1 Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Registration# License# 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 ol'Units ❑ Dumpstcrs>20 cu yd----Number ol'Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care El Acute Care ❑ Skilled Nursing El Large Generator El Small Generator El Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility,----112- 10------- ❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM Et-EMENr -I N C) FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# oc'&O PERMrr VALID to ❑ Food Handler ❑ Check f! ANIOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY -jr- 'I 11 ACCOUNTING OFFICE Date I O Masterfile Record Pink 48-02-034 10/6/2003