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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F RM ❑ New EH Program at Existing Facility __ New EH Program and New Facil Facilitv ID Record ID ?kD65' g16) RF yMENT CF�V�O JUN 84 At 1%OgQUIN �Eq�TH 0�pQ,,N7- k Facility Address '24P5'S ftV_-KLdE'Y PA -9 -t1J `t' , CA 'q i FNr (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 Make Vehicle Type _ Registration # License # Sticker # ❑ Temporary Food Facility —Dates of operation from to ❑ Special Event Dates of operation from to Color _ ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ 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) ------- — ---- ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility -------------------❑ 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 HousinglLabor 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility I ', Pool Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ 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) ❑ FarmlRanch 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 112 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON �� S Day Ph PROGRAM ELEMENT ?, FEE_ ❑ Surcharge INSPECTOR # PERMIT VALID to ❑ Check# AMOUNT PAID Date rP ❑ Cash REVIEWED BY ///� ACCOUNTING OFFICE 48-02-034 (�6 J _ 11/15/07 ight Ph ❑ Other FEE ❑ Food Handler INVOICE # Date lQ lk MASTERFILE RECORD INFORMATION PINK