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c � <br /> SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPAR NT \ <br /> 1 ` <br /> ivtASTERFILE RECORD INFORMATION FORM <br /> - <br /> �Ness EH Proaram at Existing Facility ❑New EH Pro ram and New Facibty <br /> Facility ID PA <br /> CC, -3-7-7 C1 Program Record ID '� (, I C) <br /> Facility Address S��C� -l�h i S+�����`� �o� C to I <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# License# Sticker# <br /> ❑ Mobile Food Prep Unit -`take Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser --Number of Containers in Multi-Head Unit <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 (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br /> Tiered PermittingFacilit ------------------El 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 USTA and B forms <br /> HOUSING PROGRAM(2.100) <br /> ❑ Jail or Exempt Institution------ Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> EmploNee(lousing(2700) Use Fmployee you sing/Labor Camp Applicatioat Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ElUST-CAPSite ❑ Local HW Cleanup Site ElNPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number oI'uuls'Spas at Facility C3Pool El Spa El Out of Service Pool/Spa ❑ Natural Bathing Area <br /> f <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Kennel <br /> 11Poultry Farm - <br /> -----Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4 12 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> License# Capacity Vehicle# <br /> ❑ Pumper Vehicle-Registration# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) y <br /> El Lands{{ ❑ Transfer Station g Y <br /> ❑ A /Canner Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Ree cle Facility ❑ CIA Landfill Site <br /> Waste Tire Facility El Compost Facility y <br /> ❑ Dum sters>20 cu d----Number of Units ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number of flails __ P� y <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care El Skilled Nursing El Large Generator El Small Generator El Limited Hauler <br /> El Transfer Station ❑ Veterinary Clinic E3Common Storage Facility, ❑ 2- 10------- 1311 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PfVS EHD 46-02-003 Blne Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PI(OGR:�NI ELF.NIEN"1' FEE ❑ Surcharge FEE El Other FEE <br /> INSI'EcTolt# C,CIG,C PERMrr VALID to ❑ Food Handler <br /> ❑ Check k ANIOUNT PAID Date INVOICE# <br /> �� 11 1i ACCOUNTING OFFICE ?yam Date ! <br /> 11 Cash REVIEWED BY �, <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />