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SAN JOAQUIN COUNTY ENVIRONMmEN T AL,IILALTII DEPARTMENT MASTERFILE RECORD INFORIAATION FOR11A ❑New EH Program at Existing Facility 19lew EH Program and New Facility Facil� O O 1)4% Pro ram Record ID .�3s33Z� Facility Address —7,q I (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 ❑Fending Machines—Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker,41, ❑ Temporary Food Facility—Dates of operation from to ❑ 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-Bead Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) j ❑ hazardous Waste Generator. Tons Generated Per Year ®Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(221 g) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) Tiered Permitting Facility- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Pen-nit-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 UST A and B forms HOUSING PROGRAM(2400) ❑ HotellMotel Number of Units ❑ Jail or Exempt Institution Number of Units Employee ffousing(2700)Use Employee flousinZILabor Vamp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAI'Site ❑Local MV Cleanup Site- ❑ NPLfSEP Cleanup Site ❑UIC Site ❑ Abandoned IIW Site ❑non-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ®Nater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ®Out of Ser-vice PoolfSpa ❑Natural Bathing-Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Partin Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle ❑ Pumper Ward ❑Package Treatment Plant• ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(44 0()) ❑ Landfill ❑ 'Transfer Station ❑Ag f Cannery Waste Site ❑ Sludge/Ash Site AWaste Tire Facility ❑ Compost Facility ❑ ProcessfRecycle Facility ❑ CLA,Landf Il Site ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ FarwfRauch Cleanup Site MEDICAL.WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterivary Clinic ❑ Common Storage Facility----E] 2-10--❑ 11 -60 >60 generators PUBLIC WATER;SYSTEM PROGRAM(4600) Use f If'SE[ID,16-02-003 TlrreAnn<ica(ion Fornc EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph PRocrZAm ftrNIEN T �/ Z (-p FEE ❑ Surcharge FEE ❑ Ocher FEF. INSPECTOR# �(�_ PEP1,11T VALID to ❑ Food handler 0 Check-ti, t1 mouN T PAID Date INVOICE.# _ ❑ Cash RL-VIZv.,ED BY ACCOUNT(hG OFFICE Date G!/� fZ)