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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Inucl`t'71.5J�'ll��J MASTERFILE RECORD INFORMATION FORM Inu�`�'�L.�J�IL� New EH Program at Existing Facility ❑New EH Pr gram and New Facility JUL 31 2012 Facility ID (7 13 (� Pro ram Record ID ENVIRONMENT HEALTH Facility Address 35:.5'0 e )- rA/I tsar w''4e 45-Z-0S' PERMIT/SERVICES (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❑ NoX , ttek 11 Commissary 11 Dry storage only 11 with Food Preparation ❑Vending Machines Number of Units , µ�(' 11 Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only NbOt I Mobile Food Vehicle--Make Vehicle Type Color J j 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 (2216) ------------❑ 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 ❑ 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) ❑ Tattooing (4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) - ❑ Pumper Vehicle Registration# License# Capacity 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(#of Units) ❑ Dumpsters>20 cu yd(#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 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46.02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph `7^(2 - .38`jS Night Ph PROGRAM ELEMENT IWC FEE 4 /- (a •67V ElSurcharge FEE ❑ Other FEE 7 INSPECTOR# PERMIT VALID I r3 t 11-7-- t0 -7/3 / Food Handier El heck# AMOUNT PAID 3Z�//f ACCOUNTING OFFICE Dt1 `� DOBE# ' 3D z/ Y `Cash RECEIVED 48-05 034 JUL 3 1 2012 MASTERFILE RECORD INFORMATION PINK SAN JOAQUIN COUNTY ENVIRONMENTAL