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SAN JOAQUIN COUNTY ENVIRONN ENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORIA <br /> New EH Program at Exist-ing Facility I]New EH Program and New Facility <br /> Facilit ,ID - A k W Pro ram Record ID <br /> Facility AddrCSS n, 4 `s 0( inn <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 Handlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Drystorage only ❑ with Food Preparation 11 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 PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IiAZARDOUS WASTE PROGRAM(2200)' t <br /> ❑hazardous`Paste Ge-nerat.or. - Tons Generated Per Year ❑Recycle I 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 /> ❑ Hotel/1ltotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Ifousinz/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site, ❑NPLJSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IiW Site ❑ non-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(36N) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ 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) ❑ Body Piercing(4120) ❑ Perruauent 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 /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> r-cAWaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA•Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Battler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2- 10 ❑ i l-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pif'SE ID 46-02-003 BlueApplicalion Form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON_ Day Ph Night Ph <br /> PROGR.AAtELENIFNT FEE ❑ Surcharge FEE ❑ Other FEE _ <br /> Ir+sPFcroR# - qua PEPMIT VALID to ❑ Food Handler_ <br /> ❑ check tt AM0UNT 1'.411) _ _ Date 11TV0ICE/# <br /> I <br /> ❑ Cash EVIEWED BY J� l ACCOVNTIidG OFFICE Date `� <br />