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SAN JOAQUIN COUNTY ENONMENTAL IIEALTIi DEPAR'I'W'I' <br /> MASTERFILE RI'CORD INFORMATION FORM <br /> ❑ New EH Pro ram at Existing Facility flew El-1 Pro ram and New Facility <br /> Facility ID Pro ram Record ID A2O5a3 70 <br /> Facility Address l 551 Pic <br /> (Please Check the appropriate description and specify size,number of units and uertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with hood Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage_ ❑ with Meat Markel only ❑ Multiple Departments ❑ Prcpackagcd Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vchicic•type Color <br /> Registration 11 _ License it Sticker it <br /> ❑ Mobile Food Prep Unit--Make Vchicic"Type — Color <br /> Registration 11 License 11 Sticker/1 <br /> ❑ Temporary Food Facility-----Dates of operation from - to - ❑ Ice Plan( <br /> ❑ Special Event --Dates ol'operation from to - -- ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-I lead 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 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(IST A and B form <br /> HOUSING PROGRAM(2400) <br /> ❑ 1-lotel/Motel-------Number of Units ❑ .tail or Exempt Institution-------Number of Units_ <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local IIW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQ(.:Ii Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm--------Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License it Capacity Vehicle# <br /> ElPumper Yard ElPackage Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 1 1 -60------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P1VS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 1+746,) FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 6?,L, PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02-034 Masterfile Record Pink <br /> 11/18/03 <br />