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SAN JOAQUIN COUNTY ENV ,NMENTAL HEALTH DEPARTN" T MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ___--- Ilk —_- ❑New Ell Program and New Facility /� ID FA GO SQ S L( Program Record ID___A ^�a 7 �"O- G17� mock.", L Facility _ - - Facility Address Mo i o H02-el t v'' (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes El No El ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number ol'Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type I Color Registration# License# 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-I-lead 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) ❑ 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 UST A and B fornts HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee(lousing(2700) Use Entplovee HousinelLabor Canto Annlication 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 El 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 _73-4aste 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) C1 Primary Care ❑ Acute Care 13 Skilled Nursing 13 Large Generator [3 Small Generator 13 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----C3 2- 10------- ❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM. CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT Li-7`I D + Li'-)3L FEE ❑ Surcharge FEE ❑ Other FEF INSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY (t Inti- _ACCOUNTING OFFICE / ! Date _'!5h s ` Masterfile Record Pink 48-02-034 In/60W)1