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• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> h1ASTERFILE RECORD INFORMATION F0101 <br /> WNew EH Program at Existing Facility ❑New Eli Program and New Facility <br /> Facilif ID J- Pro ram Record ID .5 <br /> Facility Address _rAV,\ SCxaq�L,I" <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> roOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ElNo El <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# Slicker# <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-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ hazardous Waste Generator-- Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Iiandlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Perruit-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 F(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlote1 Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee Ifousing(2700) Use F,mployee IfousinKobor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ En-droumental Assessment ❑ UST-CAF Site ❑ Local MV Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLISEP Cleanup Site ❑R3VQCB Cleanup Site ❑Water 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 ❑Kenuel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent 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 /> IC_7 3Vaste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle 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 /> ❑ Primat)•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) Use PIF SF.I(D d6-02-003 Blue ApPlicarion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AUDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGILMI ELFMENT L�(/ FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PEKNIFF VALID to ❑ Food handler <br /> ❑ Check 9 AMOUNT PAID _ Date <br /> 0 Cash KEVIEWEDBY ACCOUNTING r-r-tce Date <br />