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SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPARTi YT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility New EEI Program and New Facility <br /> « 1-b4 Program Record ID <br /> Facility ID v0(•� _ _.. <br /> Facility Address I I Lf C, I S. 1—}�✓�� �� <br /> (Please Check the appropriate description and specify size,number of units and Dertinent information) <br /> FOOD PROGRAM(1600) <br /> C1 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES No I] <br /> ❑ Commissary ❑ Dry storage only ❑ with 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 -take Vehicle Type Color <br /> Registration# License# Sticker# <br /> El Temporary Food Facility-----Dates of operation from to El Ice Plant <br /> 11 Special Event --Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM (2000) <br /> El Grade A Dairy El Grade B Dairy El Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous 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 USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee(lousing(2700) Use Emplovee Housine/Lahor Carnn Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-GAP Site ❑ Local HNV Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM.(3600) <br /> Number of Pool 'Spas at Facilit% ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11 Kennel <br /> ❑ Poultry Farm -------`Maxm <br /> ium number of birds <br /> TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM(4 100) <br /> ❑ Tattooing(412 l) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 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 Waste Site ❑ Sludge/Ash Site <br /> �"Ti ❑ Process/Ree cle Facility ❑ CIA Landfill Site <br /> `C'-1'—as—ty 1 ire Facility El Facility }� y <br /> ❑ Ihun isters>20 cu d----Number of Units ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number of lJnils ---_----_-_ 1 y <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> C1 Transfer Station El Veterinary Clinic ❑ Common Storage Facility----02- 10-- <br /> ---- ❑ l 1 -60 -- --❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM,(4600) Use PFVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM. <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM El.rNIEN7• Y-7110 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# CC�'_C' PERMIT VALID to ❑ Food Handler <br /> j ❑ Check N AMOUNT PAID Date INVOICE# <br /> I <br /> 11 Cash REVIBVED B1' ��. <br /> 3j3J� ACCOUNTING OFFICE ��-� Date �t2,f <br /> Masterfile Record Pink <br /> 48-02-014 <br /> 10/62003 <br />