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SAN J-OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORINT <br /> CQ New EH Program at Existing Facility El New Eli Program and New Facility <br /> Facilif 'ID FAobl{(� 3 Pro ram Record ID a ' s 7 C S3 <br /> Facility Addres.sNa-NjQAq- � �ko ren ( 9 1 S <br /> (Please Check the appropriate description and specify size,number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating CapacitySquare Footage Food handlers Course required: YESEI❑ No ❑ <br /> ElCommissary [I Dry storage only ❑ with Food Preparation ❑�'endiag Machines—Number ofUnits <br /> El Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Ychicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 11Temporary Food Facility-- 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-ITead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS`VASTE PROGRAM(2200)' a <br /> ❑hazardous Waste Generator.— Tons Generated Per Year ❑ Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers (221 s) ❑ 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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotenlote1 Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee,rousiniT/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local II`V Cleanup Site. ❑NPIdSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned Ii`V Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service PoollSpa ❑ 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(4121) ❑Body Piercing(4120) ❑ permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> [I pumper Vehicle—Registration# License# Capacity Vehicle# <br /> 11 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 Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Landfill Site <br /> ❑ Refuse Vehicles—Number of Units _ ❑ Dumpsters>20 cu)'d—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--E] 2- 10 ❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PN'SFWD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph =_ <br /> PROGRAM ELEMENT_ UI LAV FEE ❑ Surcharge Fee ❑ 011ier FEE — <br /> INSPECTOR �-WLD- PERMIT VALID ___ t0 ❑ Food Handler__ <br /> ❑ check i --.fit tc�urrl 1'�.l u - _ Date I1rv010E It <br /> ❑ Cash ACCOUNTING OFFICE Date <br />