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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD'INFORMATION FORM PECEN�� . ❑New EH Pro am at Existing Facility j2gew EH Program andNew Facility Q g 2a4g Facility ID 't ILO ram Record Iii FEB TY Sp,1y y0ApU1N C�A� � Facility Address �-F3 S iu r6- � - f t�o r 4 s xC) . �I�o sag ��TM qvp� Please Check theappropriate descri tion and If s' number of units and pertinent information. C�yob ( P specify� P ) FOOD PROGRAM(1600) SST ` ❑Restaurant: Seating Capacity Square Footage Foal Handlers Course required: Yrs❑ Nv❑ ❑ 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 F 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 Dalry ❑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 f Exempt System(2299) D CRT Offsite Handlers(221 S) ❑ Silver Only(2222) D Appliance Recyclers(2217) Tiered Permitting Facility0 Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) l ❑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(7300)Use USTA and B forms HOUSING PROGRAM(2400) 0 Hotel/Motel Number of Units -❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Em to ee'llansia /Labor Camp Applkydert Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPMEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑non-NPLISEP Cleanup Site 0 RIVQCB Cleanup Site ❑Water Quality Remediation Site " RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P401 ❑Spa D Out of Service PooVspa ❑Natural Bathing Area VIECTOR.GONTROL PROGRAM(4000) ❑Poultry Faris Maximum number of birds ❑Kennel TATTOO noDY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WAST:PROGRAM(4200) Pumper Vehicle--Registration# -T-1 U T>6A Vlro23?1Lieense# -7 -2 t 3 5'_3Capacity Vehicle-# Pumper Yard ❑Package Treatment Plant" Chemical Toilets Number of Units _Q_S SOLID WASTE PROGRAM(4400) ❑Laudfill ❑Transfer Station ❑Ag 1 Cannery!Waste Site ❑Sludge/Ash Site ❑Waste Tire Facility © Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles Number of Units ❑Dutr9ders>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care 13Acute Care ❑ Skilled'Nursing 13 Large Generator 13 Small Generator 13 Limited Hauler lS D ❑Transfer Station 0 Veterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11-60—❑>60 generators LO PUBLIC WATER_ SYSTEM.PROGRAM(4600)Use PHS EHP46-02-003 BlueApplication Form r EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM 35-S CONTACT PERSON 6 V t"ft--t 0 n.JDay Ph f'r0,S 3ENight Ph PROGitAm ELEMENT +K W FEE Surcharge FEE' ❑ Other FEE INSP€CTOP# S-q '4S4PERMIT VALID ()O to 1 y 1 01 © Food Handler ❑ Check# AMOUNT P AID 3 S S• Date a a `i INVOICE# S?3 S5 Cash REvmwEb-BY C-0 J Ci/ ACCOUNTING ONCE Date 7-1!a i9 9