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NT -,SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Y IVE R CI=1uED MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New,EH Pro ram and New Facility FacilityID o� Pro ram Record ID QUI IM COUNTY OMENTAL Facility Address 2/ L/411 54 (--2,q// C4 - _iiiird-3L HEALTH DEPARTMEW (Please check the appropriate description and specify size, 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/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 (2300) Use USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution --Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site Cl Abandoned HW Site ❑ non-NPUSEP 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) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) =Vehicle PROGRAM(4200) �S 22y umper Vehicle Registration#�� -T-3a Q, License# Capacity r Vehicle# 903 ❑ 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 (#of units) ❑ Dumpsters>20 cu yd(#or 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 ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACT PERSON J t 'z Day Ph 2d1-71/=22.73 Night Ph 9/G '��7-795O PROGRAM ELEMENT FEE " ❑ Sur Charg FE ❑ Other FEE INSPECTOR# vvv��GJ(►�/�7/ PERMIT VALID t0 I a 3 ❑ Food Handier r1 Check# AMOU ID DateW /! 16 INVOICE# 0.L-/ ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 8/02/12