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Ah SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR1 LENT MASTEREME RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility Address 1 /05 L _ Ch (Please Check the appropriate description and specify size. FOOD PROGRAM (1600) ID PR�Sa3� and pertinent information.) PAYMENT RECEIVED /�A— h ��IAR 2 3 2005 V /SA11JOAQUIN COUNTY j44NVIRONMENTAI A,,, LTH DEPARTMENT ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No'P- ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units ❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only Mobile Food Vehicle ---Make Registration # ❑ Mobile Food Prep Unit—Make Registration # ❑ Temporary Food Facility—Dates of operation from Vehicle Type License # Vehicle Type License # ❑ Special Event —Dates of operation from to DAIRY PROGRAM (2000) C'+ 4, r!' ; v� D Color =^— Sticker#— 6?37� _ Color Sticker# ❑ Ice Plant ❑ Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head 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 farms HOUSING PROGRAM (2400) ❑ HoteUMotel ---Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Rousing (2700) Use Employee Housine/Labor Camp Application 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 Pc ols/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm—Maximum number of birds ❑ 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 ❑ Waste 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) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—El 2 - 10 -- ❑ 11 - 60 ---❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PIES EHD 46-02-003 Blue Application Form CONTACT PERSON r4,/)C G'.'r,-&Cz t D Day Ph PROGRAM ELEMENT 16'3!} FEE %3 +6C{ Ire ❑Surcharge FEE 13 Other FEE IIN./SPECTOR# S47A' PERMITVALID,3323/0-T- to 1, U3 if 0S pp�❑FoodHandler pp Check # � � 03 AMOUNT PAID 4r %S .DC7 Date .3 Z D f�1NVDICE # 1314, 'YD LLI Cash REviEWEDBY AccouNnNCOFFICE Date 3 f 23 �O� 48-02-034 Masterfile Record Pink 10/6!2003