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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORI\4ATION FORM <br /> PV New EH Program at Existing Facility ❑New EH nnPro__gram and New Facility <br /> Facitif°ID F A t3(:) Pr ram Record ID 53 <br /> Facility Address �J S3r7� <br /> (Please Check the appropriate description and specify size•number of units and perfinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food handlers fours^required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to 11 ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> VA1RY PROGRAM(2000 <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' i <br /> ❑Hazardous Waste Generator.— Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) f❑ Silver Only(2222) _ ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally 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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Fmployee I rousine/Labor Camp Apalicadcn Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local I1W Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IlW Site ❑non-NPIISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility., ❑Pool ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill 11 Transfer Station 11 Ag I Cannery Waste Site 11 SludgelAsh Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA•Laadfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ASSkilled Nursing ❑ Large Generator Cl Small Generator ❑Limited hauler <br /> ❑ Transfer Station ❑Veterinary CIinic ❑ Common Storage Facility--[] 2-10 ❑ t 1-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePWSEHD d6-02-003 Blue Applica6crt Form <br /> EMERGENCY NOTIFICATION FORTHIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON_ _ Day Ph Night Ph <br /> I'ROGIum ELEl�IE 75j� IEE �� ❑ Surchar eFEE ❑ Other FEEINSPECTOR# � ERMITVALID . (� to ❑ I+ood IiandterCheck ff OUNTPetil LLAlb Date INVOICE#Cash pE%rIEACCOt7NT1TdGOFFICE ' Date �/ i <br />