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PAYIWEIIi SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECE�YED MASTERFILE RECORD INFORMATION FORM MAR' 2 01015 S ❑ New EH Program at Existing Facility ❑New EH Program and New Facili A ENVAQUIbf COUIYTV FacilityANE ID ,gcz�z183 Pro ram Record ID T t��J� ` �EAI'T"OCPANTM Facility Address Z RArl d((,V1 Cda Ivc_'iI e,4 mr �5�� (Please check the appropriate description and specify size, number of nits and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YEsNo ❑ ❑ 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 Sticker ,_,/ Registration# License# Ser# Id Mobile Food Prep Unit A7 Make 1Z ( LL�.I Ve icle Type GI/ Color Registration#/W9 5aa355z21�0 License# 'S 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 COPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) _ ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers(2218) -------------11 Silver Only(2222) ❑ Appliance Recyciers(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 cf AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A 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-NPL/SEP 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(a of Units) ❑ Dumpsters>20 cu yd I#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 ❑ 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 AND/OR PROGRAM CONTACT PERSON D0 M f1fAe Day Ph 5_/j7& Night Ph / PROGRAM EL,E/ryryryry7777ENTf FEE ❑ Surchar e 11Other FEE INSPECTOR# PERMITVAUD S to 3tF I.= ❑ Food Handler ❑ Check# ((ll AMOUNT PAIP Date INVOICE# .Z40VF23 - ❑ Cash REVIEWED B �_< ACCOUNTING OFFICE Date .3 23fs 48-02-034 �V� MASTERFILE RECORD INFORMATION PINK 11/15/07