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SAN JOAQUIN COUNTY ENVIRONNI,ENTAL HEALTH DEPARTNIENT <br /> MASTERFILE RECORD INFORMATION DORM <br /> New EH Progra n at Existin Facility w EH Program and New Facility <br /> ' <br /> Facilit ID � oG�� � Program Record ID <br /> Facility Address // `t c.) i1 -K^ M-- <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 ElDry storage only Elwith 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 it License# Sticker# <br /> El Temporary Food Facility—Dates of operation from to ElIce Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispeuser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' i <br /> ❑hazardous Waste Generator.-- Tons Generated Per Year ❑ Recycle I 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 LISTA and B(orrrrs <br /> HOUSING PROGRAM(2400) <br /> ❑ 110tenlotel Number of Units -❑Jailor Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee ITousigjz L bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAF Site ❑Local II1V Cleanup Site. ❑NPLlSEP Cleanup Site ❑UTC Site <br /> ❑ Abandoned IINV Site ❑ non-NPLISEP Cleanup Site ❑R\VQCB Cleanup Site ❑ \Pater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery\Vaste Site ❑ CIA-SludLand Site <br /> Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA•Landfill Site <br /> ❑Refuse Vehicles—Number of Units _ ❑ Dumpsters>20 cu yd—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-I0 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P1f'SEHD M-02-003 BlrrcApplica(ion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT_ ­17ql) FEE —1 ❑ SurchargeFEE ❑ O(ber FEE — <br /> INSrECTOR# e7Z�Q— PERMITVALID "�,1"{ to �(� �7i ❑ food Handler__ <br /> 'Date IrIV010E{# <br /> ❑ Cash REVIE\VF.DBY AccouNTII:GOFFICE Date C/ ____ <br />