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SAN JOAQUIN COUNTY EN NMENTAL HEALTH DEPART T <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH Program at Existing Facility []New EH Prop-ram and Nepw Facilit <br /> [Facility ID F4 6010c/8 Program Record ID <br /> Facility Address y 30 / N• OUt?t-o-tvn - <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Sealing Capacity Square Footage Food Handlers Course required: l'r;s El No 11 <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 Vehicic Type Color <br /> Registration# License# Sticker# <br /> El Temporary Food Facility-----Dates of operation from to El lee Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> El Grade A Dairy ❑ Grade B Dairy 13 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------------------❑ 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 fornns <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee Housing(2700) Use Employee Housiup/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site Cl Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool El Spa [I Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Kennel <br /> ❑ Poultry Farm -------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) 11 Body Piercing(4120) 11 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C3 #Pumper Vehicle -Registration <br /> License# Capacity _ Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill 13 Transfer Station El Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Ree cle Facility El CIA Landfill Site <br /> Waste Tire Facility El Compost Facility Y Y <br /> ❑ Refuse Vehicles--Numbcr of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Nursing ❑ Large Generator El Small Generator 11 Limited Hauler <br /> ❑ Primary Care ❑ Acute Care <br /> El Transfer Station Cl Veterinary Clinic ElCommon Storage Facility----El 2- 10------- E] 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON a Day Ph Night Ph <br /> F <br /> ENT !? O FEE ❑ Surcharge FEE <br /> El Other FEE <br /> 0t9p PERMI'i'VALID to Food Handler <br /> AMOUNT PAID Date INVOICE# <br /> REVIEWED BY Irk `'/ (3 5 ACCOUNTING OFFICE �� Date 7 /S D� <br /> Masterfile Record Pink <br /> 48-02-034 <br /> I nn,nnm <br />