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SAN IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LMASTERFILE RECORD INFORMATION F9RM ❑ New EH Program at Existing Facility ew EH Program and New Facility i Facility ID 61S Program Record ID f iQZ Z3 Facility Addres lI irn l of &bY421Sy1� (Please check the appropria description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacl Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage on ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market--Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mob'le 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 operatio from to ❑ Ice Plant 0-Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Numbe of chemicals: ❑ CaIARP Program ❑ Program 1 Facility Program 2 Facility El Program 3 Facility ❑ Hazardous Waste Generator(2200)-------->-Tons General d Per Year ❑ Tiered Permitting Facility-----> ❑ CA(2232) ❑ CE (22 3,2234, 2235, 2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA an forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel---Number of Units ❑ Jail Exempt Institution ----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application F m SITE MITIGATION(2900) UNDERGROUND INJECTION ONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site El Abandoned HW Site Elnon-NPLISEP Cleanup Site 11RWQCB Clea p Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ spa ❑ Out of Se 'ce 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 A Facility-Sin FAX ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body A Temp Ever6Q� ' (4131) LIQUID WASTE PROGRAM (4200) 1n1�� t021 ❑ Pumper Vehicle Registration# License# Capacity Palm G ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Num r of Uni sJ9PQidlu rnUNTY NTAL SOLID WASTE PROGRAM (4400) ENVIRON��MAAERRTMENT ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ klklasne ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ Landfill Site ❑ Refuse Vehicles p or units) ❑ Dumpsters>20 cu yd I#of Units) ❑ Fa /Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator imited 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 [- a I� �a ti J-,t2 Day PhI 2Q1=-0991" PROGRAM ELEM NT FEE Q ❑ Surcha ge FEE ❑ Other FEE INS�P/F�C�T,OR# 1 PPERMIT VALID 7/F� t0 , F od�Handler ❑�Cp'e8k Z(7 T MOUNT PAID Date 7� '7� 7� ice# ❑ Cash REVIEWED BY Wu ACCOUNTING OFFICE41� Date /wfr4 48-02-034 MASTERFILE RECORD INFORMATION PINK 1123113