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SAN JOAQUIN COUNTY E . ONMENTAL HEALTH DEPAR NT <br /> MASTERFILE RECORD INFORMATION FORNI <br /> New EH Program at I xisting Facility ❑New EH Program and New Facility <br /> Facility ID PA- 0 N Program Record ID <br /> Facility Address - 15:5 i F—: M CA;L0 S+- p <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 -Make Vehicle Type Color <br /> Registration# License# Sticker <br /> 11 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 /> ❑ 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------------------[I 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 GSTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> ❑ hotel/Motel-------Number of Units Jail or Exempt Institution-------Number of Units <br /> Employee Ilousing(2700) Use Employee Housino/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HN1'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Peels/Spas at Facility El Pool El Spa ❑ Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El 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# Capacity Vehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ElLandfill El Transfer Station 1:1 Ag/Cannery Waste Site)jZ ❑ Sludge/Ash Site <br /> ❑ Process/Recycle cle Facilit El CIA Landfill Site <br /> Waste"fire Facility ❑ Compost Facility Y Y <br /> ❑ liefuse Vehicles--NUmbCI'of Units _ ❑ DumpsterS>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care ❑ Acute Care ❑ Skilled Nursing El Large Generator El Small Generator 1:1 Limited hauler <br /> El Transfer Station ❑ Veterinary Clinic El Common Storage Facility----❑ 2- 10------- 11 11 -60 -----E3 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS END 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAMA <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGR,%Ni EL4�t <br /> EMENT t 0 FEE ❑ Surcharge FEE ❑ Other FEE <br /> I'N'SPECroli# 00 0 PERMIT VALID to ❑ Food Handler <br /> ❑ Check✓: AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY a(d o 3 ACCOUNTING OFFICE Date f D 4S� <br /> Masterfile Record Pink <br /> 411-0,-034 <br /> 10'6 2-003, <br />