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AML <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR NT <br /> MASTERFILE RECORD INFORMATION FORr1 <br /> ❑New EH Pro am and New Facility <br /> �EHro�'am�Ex�ipin Facility /��/ProgramFaciA�, <br /> Facility Address �r l5 � �9 4 <br /> (Please Check the appropriate description and specify size,numbe_ r___of units and pertinent information.) <br /> FOOD PROGRAM(1600) -- Food Handlers Course required:—YES❑ No❑_ <br /> ❑Restaurant: Seating Capacity Square Footage <br /> ❑ ❑Vending Machines--Number of Units <br /> Commissary ❑ Dry storage only <br /> ❑with Food Preparation <br /> [I with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods y <br /> ❑ Retail Market----Square footage Vehicle Type Color <br /> ❑ Mobile Food Vehicle-----Make Sticker ker# <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility-----Dates of operation from to 11 to <br /> Stand <br /> ❑ Special Event --Dates of operation from <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade B Dairy [I DlilkDispenser---Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> COPA ❑ State Facility Surcharge(2399) — 2!� <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year SO dC! ❑ Recycle/Exempt System(2299) <br /> Hazardous Waste Generator------------ ��� ❑ A liance Recyclers(2217) <br /> (2___ <br /> CRT Offsite Handlers(2218) ❑ Silver OnlyPP <br /> ) <br /> Tiered Permitting Facility-------- <br /> ------- ❑ Conditionally Authorized(CA) 11Conditionally 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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> 11.� ❑ Jail or Exempt Institution-----Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> mplot°ee Housing/Labor Camp Application Form <br /> Employee Housing(2700)Use E <br /> UNDERGROUND INJECTION CONTROL(3000) <br /> UIC Site <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW❑ CR1"QCB Cleanup Site NPL/S0 <br /> Water Quality Reme❑ <br /> SITE MITIGATION(2900) dlation Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility <br /> ❑ Pool ❑ Spa [I Out of Service Pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm---Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT 0 Body PierMETIC cing(412)OGRAM(4100) Cl Permanent Cosmetics(4122) <br /> [I Tattooing(4121) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# <br /> ❑ Pumper Vehicle--Registration# El Chemical Toilets-------Number of Units <br /> ❑ Pumper Yard [I Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) C3Sludge/Ash Site <br /> ❑ Landfill <br /> ❑ Transfer Station ❑ Process/Recycle Facility❑ Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility [3Farm/Ranch Cleanup Site <br /> 11 Refuse Vehicles--Number of Units ❑Dumpsters>20 cu y d---Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ln Oil - <br /> PUBLIC 60-----❑>60 generators <br /> ❑ Transfer Station ❑Veterinary Clinic <br /> ❑ Common Storage Facility-----❑ 2-10------- <br /> WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 BlueADnlication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON ❑ Other FEE <br /> FEE RYW 21016 ❑ SurcbargeFEE <br /> FPROGRAmELEINIENTJJ�.� to ❑ Food HandlerPERMIT VALID I 2� DateINVOICE# <br /> AMOUNT PAID TU te // �REVIEWED BY ACCOUNTING OFFICE Masterfile Record Pink <br /> 48-02-034 <br />