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RFyRe C�c(T j ^ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT VEa MASTERFILE RECORD INFORMATION F M A AN 04 ❑ New EH Program at Existing FacilityNew EH Program and New Facill SVR Qu/jv Facilit ID �� Program Record ID �A�rN0 _)V7 ), Facility Address '2lP5� �KVJ - � , CA 4�Nr (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle —Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit Registration # ❑ Temporary Food Facility —Dates of operation from ❑ Special Event Dates of operation from DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy Make License # to to Vehicle Type Color Sticker # _ ❑ Ice Plant ❑ Produce Stand ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ------------- El Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ------------------- 11 Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel ----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ( Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ A Spa TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel ❑ Permanent Cosmetics (4122) ❑ Pumper Vehicle Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON JCtW Day Ph 3 light Ph 2c�'11 • C5 S • 317 PROGRAM ELEMENT FEE 1:1 Surcharg Fe ❑ Other FEE INSPECTOR # PERMIT VALIDa ZD t0 3 � ElFood Handler 11Check #� AMOUNT PAID• OD Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11115107 / "7�--