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SAN JOAQUIN COUNTY EI JNMENTAL HEALTH DEPART] T MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility tiew EH Program and New Facility Facilit ID (gCS 7 Program Record ID 5 -7-3 cf Facility Address I: 3 S� MCan `�st- (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License r Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# License= Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit CUPA ❑ State Facility-Surcharge(2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility------------------11 Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM (2300)Use CSTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee Ilousing(2700) Use Employee flousine/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HNN'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned FIW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN QCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm -------- number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle -Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--=---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site Waste Tire Facility ❑ Compost Facifity ❑ Process/Recycle Facility ❑ CIA Landfill Site i 1 Itcfuse Vehicles--NUMI)CI of l)nils ElDumhsters>20 cu yd----Number of Units _ ❑ }Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----112- 10------- ❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON i, Day Ph Night Ph PROGRAM Et.ENIFN1' I FEE ❑ Surcharge FEE ❑ Other FEE INSI'E(:roa.# 00(G U PERMIT VALID to ❑ Food Handler ❑ check# ANIOUNT PAID Date INVOICE 4 ❑ Cash RevIEWED BY C'L ACCOUNTING OFFICE '�� Date 113 D (o 48-02-034 Masterfile Record Pink 10/6/2003