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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERRLE RECORD INFORMATION FORM J� ew EH Program at Exisfin Facility ❑New EH Program and New Facility Facilit iD b Pro ram Record ID SEP 2OW8 tNz( SAN JOAQUrlVFacility AddressANVIFION N (Please"Check the appropriate description and specify size,number of units and pertinent information.) N ALTH'DERA� FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Feuding Machines—Number of Units ❑ Retail Mark=et----Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only ❑Mobile Food Vehicle----Make Vehicle Type Color Registration# License It 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(2004) ❑Grade A Dairy ❑ Grade B Dalry ❑Mill:Dispenser—Number of Containers in Multi-Head Unit ~ CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) i' ❑Hazardous Waste Generator" Tons Generated Per Year ❑Recycle f Exempt System(2299) ❑CRT Offsite Handlers(2218) L7 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 f ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B,Lorms : HOUSING PROGRAM(2400) ❑TioteUMotel Number of Units _❑Jail or Exempt Institution Number of Units Empl©yee Housing(2700)Use Emproyee Housinz4abor Camp Applicrrtioa Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3004) ElEavironmental Assessment 0 UST-CAP Site E3Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site } _ ❑Abandoned HW Site ❑non-NPLISEP Cleanup Site ❑RWQGB Cleanup Site ❑Water Quality Remediation Site • RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑Pool ❑Spa 0 Out of Service PoollSpa ❑Natural Bathing Area" VECTOR.CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO 13ODY PIERCING PERMANE=NT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) Cl Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle ft I ❑Pumper Yard P elca ge Treatment Plant- ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag I Cannery Waste Site ❑Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA,Landfill Site ❑Refuse Vehicles--Number of Units ❑Dumpsfers>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Stalled Nursing ❑Large Generator Q Small Generator ❑Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑Common Storage Facility-----❑ 2-10 ❑ 11-60-----0>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use P_li'SEMD46-02-003 BlueAmlica(ion Form EMERGENCY NOTIFICATION FOR This FACILITY ANDIOR PROGRAM CONTACT PERSON ✓r 331" 2f q Day Ph &4 331 - 7000 ._ Night Ph 2 •5aL-_2600 PROGRAM ELEMENT' FEE v q�` b ❑ Surcharge FEE ❑ Other FEE tiVSPECT08# PERMIT VALID to to '(' ❑Food Handier Check# a C,_S S Z AMOUNT PAID S CTD , (SI) ` Date D r6—INVOICE# �l�ylrUhr� Cash RuviEWEDBY ACCOUNTING OFFICE Date 10h Va a•__._1:1_h......�.i T?:..ice r