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SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPARTT, t T <br /> MASTERFILE RECORD INFORMATI. N FORM <br /> EJ New EH Proeram at-Existing Facility New EH Proeram and New Facility <br /> Facility ID D0 loS �S Program Reco d ID <br /> Facility Address oZ�? San�lnetrc Ln p <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes El No El <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 -Make 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 Permitting Facility------------------11 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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee(lousing(2700) Use Employee flousin,-Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 1:1 Environmental Assessment ElUST-CAPSite El Local FINN Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ R«'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools,'Spas at Facility [1 Pool El Spa 11 Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 13 Poultry Farm -------Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM 14100) <br /> 11 Tattooing(4 12 1) ❑ Body Piercing(4 1'-0) 11 Permanent Cosmetics(4 122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package 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"fire Facility ❑ Compost hacility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--NUmbCr of Units ❑ Dumpsters>20 cu yd----Number of Units _ _ ❑ Farm/Ranell Cleanup Site <br /> MEDICAL WASTE PROGRAM(400) <br /> 11 Primary Care El Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generator El Limited Hauler <br /> El Transfer Station El Veterinary Clinic El Common Storage Facility----❑ 2- 10------- 1111 -60-- <br /> >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS 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 K-7'(b FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# OO(Q O PERMIT VALID to ❑ Food Handler <br /> ❑ Check# A.MOUNT PAID Date INVOICE# <br /> ❑ cast, REV[FWED uY�2 in/7_7105 ACCOUNTING OFFICE <br /> __/ Date < < Z(b <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10.'6:2003 <br />