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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORIA <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ID 0 4 Pro ram Record ID p.. u`' 6 <br /> Facility Address 1 } r' y R n r�'v c . _ S Z K ►��' <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No 11 <br /> ❑ Commissary ❑ Dry storage only 11with 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# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to 11 Ice Plant <br /> ❑ Special Event —Dates of operation from to 11 Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ )lf <br /> El Grade A Dairy 11 Grade B Dairy ilkDispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) a <br /> ❑ Ilazardous 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 /> ❑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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Ilotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units' <br /> Employee housing(2700)Use Finployee flousineffabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local HW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> 11Abandoned IiW Site 11 non-NPL/SEP Cleanup Site 11R\WQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 11 Pool 11 spa El Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) El Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill 11 Transfer Station 11 Ag/Cannery Waste Site 11 SludgelAsh 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/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care 11 Acute Care 11 Skilled Nursing 11 Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--13 2- R) ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pll S E1[D 46-02-003 Blue Application Fonn <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 3�Z FEE ❑ Surcharge FEE ❑ Other FEE <br /> 1NSPEcrOR# 24 PERMIT VALID . to ❑ Food Ilandler <br /> ❑ Check# AMOUNT PAID Date h 1• IC) INVOICE# n <br /> ❑ Cash REVIEWED BY Ar ACCOUNTING OFFICE _Date <br /> M"t"f;1P R­,d Pink <br />