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l � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DI 'ARTMENT <br /> MASTERFILE U. CORD INFOR1\1ATION FUI01 —s— <br /> KNew EH Program at Existing Facility ❑New E I I Program and Ner),Facility <br /> I Facility IDf A a�3 � Program Record ID }Dt2 t7 S3 <br /> N <br /> Facility Address v e ). Air, no <br /> (Please Check the appropriate description and specify size,number o units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Ilandlers 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 PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispeaser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) � <br /> ❑ hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CP\.T Offsite Ilandlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pernut-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Wastc <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ IlotcUlAote] Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Ilousiag(2700) Use Errrpta yee Ilousinr•/Labor Camp Application Form <br /> SITE MITIGATION(2940) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAroameatal Assessment ❑ UST-CAP Site ❑ Local IIIV Cleanup Site ❑ NPLfSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLISEP Cleanup Site ❑R\N'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Senice PooUSpa ❑ Natural BathiagArea <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Penuauent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle ft <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA.Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd--Number of Units ❑ Farm/Raach 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 -60-11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Usc Pif-S F11D 46-02-003 Blue Application For-n! <br /> EMERGEPICY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day I'h Night Pb <br /> PROGRAM ELEMENT /-/74/0 FEE ❑ Surcharge FEE ' ❑ Other FEE <br /> INSPEC 0P,# ,26'.0 PEB1,111-VALID _ to ❑ Food Handler <br /> ❑ AMOUNTPAID —__-- Date Itrvolcl:# _ <br /> ❑ Cash Rr_vIEwED BY AccoUarING OFFICE <br />