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SAN JOAQUIN COUNTY Ei AONMENTAL HEALTH DEPAR', NT <br /> MASTERFILE RECORD INFORMATION FORA <br /> New EH Program at Existing Facility ❑Ne�� EH Program and New Facility <br /> Facility ID FQ C(-) II 1713 Program Record ID <br /> Facility Address a31R 2? k�e-L✓- 41- <br /> (Please <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 Onh <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------------------❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Pert-nit-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 Limns <br /> HOUSING PROGRAM(2400) <br /> ElHotel/Motel-------Number of Units C1Jail or Exempt Institution-------Number of Units <br /> Employee 11ousing(2700) Use Employee Hvrrsino'Lnhor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HNN'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 /> NUrnber of Pools/Spas at Facilit} [I Pool 11 spa C1 Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm -------Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(3200) <br /> ❑ Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill ❑ Transfer Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Ree cle Facility ❑ CIA Landfill Site <br /> I�Wastc'1'irc Facility ❑ Compost Facilih• Y Y <br /> ❑ Refuse Vehicles--NUn1bCI'of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care ❑ Acute Care El Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler <br /> ❑ "Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----❑ 2 - 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS EHD 46-02-003 Blue Application Forn, <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM EI.ENIENT �'7qD FEE ❑ Surcharge FEE _ ❑ Other FEF. <br /> INSI.FC'r01;# dOb PERMITVALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ■ Cash REVIEWED BY �,tP_ cl/2-9L05 ACCOUNTING OFFICE Date C) 610, <br /> Ntastertile Record Pink <br /> 48-02-033 <br /> 10/6/2003 <br />