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:a 4. J. rl\ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P'AY'` E i MASTERFILE RECORD INFORMATION FORM RECEIVED ❑New EH Program at Existing Facili ew EH�1Program and New Facility N O V 0 8 2006 FacilityID U D (PID 0--z-1Pr2ram Record ID r�tJ S~ �-� SAN JOAC�UIN COUNTY Facility Address 1 VeX e/y i� J ENVIRONMENTAL HEALTH DFpARTMENT (Please Check the appropriate description and specify§iM 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 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(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle 1 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(23 00)Use UST A and B forms MOUSING PROGRAM(2400) ❑ Hote"lotel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Housingl abor 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 ❑ 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) ❑ Tattoolug(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(42 Pumper Vehicle--Registration - License# Capacity 1139 C-* ._. 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-Number of Units ❑ Dumpsters>20 cu yd----Number 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--0 2-10-----❑ 11 -60-----❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS EHD 46-02-403 Blue Application Form Emr=RGENCY NOTIFIcA'r1ON FOR THIs FACILITY RAND/OR PROGRAM �� CONTACTPERSON�,t�rctJJ1.5__ i h�t//r1%��✓�_ 51 �, Day Pik-fir% �✓ 7 7/ Night P �G7,) 3 PROGRAM ELEMEN 7 FEE 3 ,>,j- ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID !I ?10 i-m to C3 O 6 _ ❑ Food Handler Check#—/O (D AMOUNT PAID �i3S r Date VOL Irrvolce# 153 x-37 Cash REVIEWED BY ACCOUNTING OFFICE Date Z ( D 48-02-034 Masterfile Record Pink