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R qY��N SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART ENT �� ' MASTERFILE RECORD INFORMATION F RM JAIv ❑New EH Pr ram at ExistingFacilityNew EH Pr ram and New Faclll SgN40 ,8 ZO�� Facill ID �2J� �-- P ram Record ID a� (o y R v/p Facility Address b C f-V 4 (A 61 5 tW (Please check the appropriate description and specifyiLIM 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 Mending 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 Prop 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 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/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 UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑Jail or Exempt Institution----Number of Units Employe*Housing(2700)Use Employee HoualnQ/Labor Camp ApplMatlon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas 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) 13 Tattooing(4121) 13 Body Piercing(4120) Permane Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# CapaciyVehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ ChernhW Toilets—N9ml56r of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tiro Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 ou yd w of units) ❑ Farm/Ranoh Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Caro ❑Acute Caro ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑Transfer Station ❑Veterinary Clinic Q Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 48-02-00$Blue Applies tlOn Form CONTACT PERSONDay Ph q 5 `l Night Ph q 5 7- PROGRAM ELEMENT 'jl to FEE ❑Surcharge FEE ❑ Other FEE INSPECTOR# 2_lo-7-ZPERMIT VALID 1 t0 '-7 ❑ Food Handler Check# log( AMOUNT PAID Date ( INVOICE# a Cash REVIEWED BY ACCOUNTING OFFICE Date 8 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07