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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORIA <br /> ew EH Program at Existin Facility ❑New EH Program and New Facility <br /> Facilit •ID 'A FA J 9 61-IA Pro ram Record ID <br /> Facility Address "l11�'L (ItLr i Aum- KC) - <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food handlers Course required: YESD❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only 11 with Food Preparation ❑Fending Machines—Number of Units <br /> El 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 /> 11 Grade A Dairy 11 Grade B Dairy ❑ I\filkDispenser—Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) a <br /> [I Hazardous Waste Generator— Tons Generated Per Year ❑ Recycle/Eaempt 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 Corms <br /> HOUSING PROGRAM(2400) <br /> ❑Ilotel/Motel Number of Units ❑ Jailor Exempt Institution Number of Units <br /> Employ"housing(2700)Use Fmployee Iforrsin,e/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑Local IIW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLlSEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 13 Pool ❑ Spa ❑Out of Service Pool/Spa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [IPoultry Farm Maximum number of birds ❑Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> [I Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> [ILandfill 11Transfer Station 11Ag/Cannery Waste Site 11 Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu.yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator [ Small Generator ❑ Limited hauler <br /> 11Transfer Station ElVeterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11 -60_E] >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UscPHS G•IID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRANI ELEMENT x175/0 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# L26Q_,:Q _ PERMIT VALID to ❑ Food Handler_ <br /> ❑ Check#_ AMOUNT PAID _ _ DatC ]TI-VOICE-# / --- -- <br /> ❑ Cash fLEVIEWED BY ACCOUNTING OFFICE _ Date <br />