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SAN JOAQUIN COUNTY ENVIRONMENTAL IILALTII DEPARTA']ENT <br /> MASTERFILE RECORD INFORMATION FORINT <br /> QkNew EH Program at Existing Facility ❑Neer EH Program and New FFaaccility <br /> Facilit ,B) Pro ram Record ID al S 3 o V <br /> .FacIIIty Address 7�"1.� �,nr v�srnL� l l CAXK VV <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Ila rid lers Course required: YES ❑ No ❑ <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—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from - to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAh1(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IiAZARDOUS WASTE PROGRAM(2200) t <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 /> ❑Per iit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Ifousirri/Tabor Canrp Applicadair Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAronmeatal Assessment ❑ UST-CAF Site ❑ Local IIW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UiC Site <br /> ❑ Abandoned 111Y Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑ !Yater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Senice PoollSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License it Capacity Vebicle tl <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/Asir Site <br /> AWaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units _ ❑ Dumpsters>20 cu yd—Number of Units ❑ Farmf auch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited IIauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----E] 2- 10--❑ 11 -60-----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)USCPffSFl(D f6-02-003 Mac Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT'PERSON Day Ph Night Ph <br /> I'ROGR.AAi ELFNIENT 'L/�� FEE ❑ Surcharge FEE '. ❑ Other FEE <br /> INSPECTOR# � PER-MIT VALID _ to ❑ Food Handler <br /> ❑ elicck 9 AMOUNT PAID Date Irrvolcf--# _ <br /> ❑ Cast, REVIEWED BY A,COUNTIN6 OFFICE - _ Dalc <br />