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SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPART T D MASTERFILE RECORD INFORMATION FORM JAN 2,0 2012 New EH Program at Existing Facility ❑New EH P ram and New Facility t l Facilit ID Program Record ID � ? ENVIRONMENT HEALTH Facility Address S50 S c �MQ SCG 2 I N - S Le- 67 L oor , (A - 9 Sc?� U PERMIT/SERVICES (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM 0600) 13 ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No ❑ Commissary 13Dry 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 Color Registration# License# Sticker# ❑Temporary Food Facility–Dates of operation from to ❑Ice Plant ❑ Special Event Dates of operation from to ❑ 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(220) ❑Hazardous Waste Generator Tons Generated Per Year ❑ RecyclelExempt System(2299) ❑ CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyders(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 farms HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑Jail or Exempt Institution—Number of Units Employee Housing(270)Use Employee HousimalLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(300) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(360) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(400) ❑ Kennel ❑ Poultry Farm---Maximum number of birds TATTOOBODY PfERCMI- PERMANENT COSMETIC PROGRAM(410) Tattooing(4121) o� ��j(�Q �A1❑ Body Piercing(4120) I ❑ Permanent Cosmetics(4122) �(!J�CIUID WASTE PROGRAM(200) ❑ Pumper VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(440) ❑ Ag/Cannery Waste Site ❑ La Sludge/Ash Site ❑ Landfill ❑Transfer Station CIA ❑Waste Tire Facility ❑ Compost Facility ❑ ProcessiRecycle Facility ❑ ar Landfill Site F ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site mEpiceL WASTE PROGRAM(4500) ❑Skilled ❑ Primary Care ❑ Acute Care Nursing ❑ large Generator ❑Small Generator ❑ Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(460)Use PWS EHD 46-OAM Blue Application Form EMERGENcy NOTIFICATION FOR is FACILITY ANDIOR PROGRAM CONTACTPERSON SOUK Pt-fTA N&S11tAl, Day Ph ?.� [;3 fj Night Ph(,2C'6)) 3'IA -21 L PROGRAM ELEMENT� FEE ❑Surcharge FEE ❑Other FEE INSPECTOR; PERmrr VALID to ❑ Food Handier ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE LL Date MASTERFILE RECORD INFORMATION PINK 48-42-034 11/15/07