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w � <br /> SAN JOAQUIN COUNTY ENVIRONIMENTAL HEALTii DEPAR"1TNIEN"I <br /> MASTERFILE RECORD INFORMATION FOIZ11 <br /> &41ew Eli Program at Existia Facility _ ❑New Irll Program and I co,Facility_ <br /> Facilif}'II) � 7� Pro7,rant Rccord ID <br /> Facility Address X1-73 GJ `�o�ml, � �►r� <br /> (Please Check the appropriate description and specify sjLe number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ Mth Food Preparation ❑Vendiap Machines—Number of Units <br /> ❑Retail Market—Square footage ❑wilh Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration 9 License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Veliicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to 11 Ice Plant <br /> ❑ Special Eyeat —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ hldk-Dispeaser--Number of Containers in Aiulti-Bead Unit <br /> CUPA ❑ Slate Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) I <br /> ❑hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(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(array <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotenlotel Number of Units ❑ Jail a Exempt Institution--Number of Units <br /> Employee Ifousiag(2700) Use Fnplayee IfousinelLabor Camp APpfication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ En`ironinea(al Assessment ❑ UST-CAP Site ❑ Local IM Cleanup Site ❑ NPL/SEP Cleaaup Site ❑ UIC Site <br /> ❑ Abaadooed IIW Site ❑ non-NPLISEP Cleanup Site ❑R)N'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(300) <br /> ?dumber of PooWSpas at Facility ❑Pool ❑ Spa ❑ Out of Senice Poouspa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO,13ODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Pernraaeat Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pump er Veliicle—Registration License# Capacity Vehicle# <br /> ❑ Pumper Pard ❑Package Treatment Plant- ❑ Chemical Toilets—1,lumber of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery 1Vaste Sitc ❑ Slud e/Ash Site <br /> A.3yaste Tire Facility ❑ Compost Facility ❑ I'rocess/Recycle Facility ❑ CIA.Landfill Site <br /> ❑Refuse Vehicles—Numbcr of Units ❑ Dumpsters>20 cuyd —Number of Units ❑ Farm/I:?ucli Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veteriaary Clinic ❑ Common Storage Facility---E] 2- 10---❑ 11 -60--- ❑ Go generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PHSFfll) I6-02-003 Rlrrc:tpplica(ion Form <br /> EUIERGENCY NOTIFICATION FOR Tt1IS FACILITY ANDIOR PROGRAM <br /> CONTACTPERSON Day Ph Night Ph <br /> I'I2tiGR+ttt T.LE;�iFl�l —i�L��— FEE _ -T-- 1-1— Surcharge TEF T ❑ Other C,.:E — <br /> Irgsctcrotr: o?E,a� F I_Ittn `dALID to ❑ Food handler <br /> ❑ Cliccl.-;- (.T�t(�t�i•ts1'.�tt> ___ __ D?l.. _ Iitl'Oh't:11 __ -- <br /> ❑ (=t�h I'.F"tt".I:L)It <br />