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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I pwY RENT <br />MASTERFILE RECORD INFORMATION FORM RECFNED <br />V,fNcw EH Pro at Existing Facility ❑New EH Program and New Facility <br />Facility ID 1 Q1 T i 1 Program Record ID PRD 53 ,� oNGvA � <br />Ft e4 -,,J , fel i_ CA C Q 5`L SI 1] 5A ENV. pEPA �''tENT <br />Facility Address J� 4N.� <br />(Please Check the appropriate description and specify>� number of units and Dertinennt /i�nfoyrmation.) 3 12 <br />FOOD PROGRAM (1600) ` R V S 3 n(�\— <br />❑ Restaurant: Seating Capacity SquareFootage Food Handlers Course required:. YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Vending Machines —Number of Units <br />❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility --Rates of operation 8 <br />❑ Special Event —Dates of operation from <br />Vehicle Type <br />License # <br />_ Color <br />Sticker # <br />Vehicle Type Color <br />License # Sticker # _ <br />❑ Ice Plant <br />Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Datry ❑ Grade B Dairy ❑ Mirk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200)' I <br />❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (2219) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />D Pemtit-By-Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ IIotel/Motel Number of Units ❑ Jail or Exempt Institution —Number of Units <br />Employee Housiag (2700) Use Fmplo#ec Housing/Labor Cama Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UTC Site <br />D Abandoned IiW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (36 <br />Number of Pools/Spas at Facility �i Poo! fSpa <br />) out <br />of Service Pool/Spa 13 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) ��/( ```_ <br />❑ Poultry Farm—Maximum number of birds ❑ Kennel <br />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) - ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />[I Pumper Vehicle—Registration # License# Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters> 20 cu yd —Number of Units ❑ Farin/Rauch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator D Small Generator D Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—[] 2 - 10 — ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVSERD 46-01-003 Blue Application Form <br />CONTACTPERSON Y ck Q M O Day Ph Night Ph <br />PROGRASIELFMENT c3Cofl .3 <br />r &[2—FEE 11SurcLarge FEE . [I Other FEE <br />INSPECTOR# C°Z(3 � PERMITVALID . 2 Q- to l2 -131,109p ❑ Food Handler <br />ChI <br />eck# 3 1 6 ! AMOUNT PAID fl Z. 5D Date 0 1 �) INVOICE# <br />❑Cash REVIEWED BY 03z ACCOUNTING OFFICE Date —1 <br />