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SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTII DEPARTIV ANT MASTERFILE , )RD INFORMATION FORM ❑ New EI I Pro gram at Existh%Facililx IgNcw EI I Pro gram and New Facility Facility IDG0 13 5 Program Record II) AO S a lo�oZ Facility Address ) +)L+ G SZOC' (Please Check the appropriate description and specify size,number If units and pertinent information.) FOOD PROGRAM(1600) ❑ RestauralIC Scaling Calmcily Silnarc Foolagc Food Ilaudlers Course required: VKS❑ No ❑ ❑ Conunissary ElI)ry storage only El Willi Food Preparation ❑Vending Machines--Number of Units El Retail Market----Square footage ❑ Willi Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration II License II 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-licad 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----------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permil-lay-Rule I.,ixed t)nil ❑ 11ermit-I3y-Rule Ilouschold Ilazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UND1,A(GROUND STORAGETANK GIST) PROGRAM (231111) Rvc USTA and B farms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Housing/Labor Cancp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB 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-------Maximum number of birds _ ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ 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 Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>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-----02- 10-------❑ 1 1 -60------1:1 >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 Day Ph Night Ph PROGRAM ELEMENT 4-1 q FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID `7(1 I O to 143 O(O� ❑ Food Handler ❑ Check# AMOUNT PAID -i�__ Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date (o D 48-02-034 Masterfile Record Pink 11/18/03