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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />TIONA TH DEPARTMENT <br />MASTERFILE RFCF V� r <br />ew EH Program at Existing Facility ❑New EH Program anFacH <br />d New it SAN <br />A✓J� <br />lits ID VA nG a S Program Record ID AO54%qOs Eti OgOr„ ?? <br />Facility Address old V4ogj* Garde. /_ods 0#.4 `I5ayq ` HOEp14 Nr' 7T_ <br />(Please check the appropriate description and specify size, number of units and Pertinent information.) QRrMENT <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity _ Square Footage 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 Vehicle Type Color <br />Registration # License # Sticker # _ <br />❑ Mobile Food Prep Unit Make Vehicle Type <br />Registration # License # Sticker # _ <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Color <br />Ice Plant <br />❑ Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator -------Tons Generated Per Year _ ❑ Recycle/Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility --•------------❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -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 LISTA and B forms <br />HOUSING PROGRAM (2400) <br />Dj} o e Motel—Number of Units 702 ❑ Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 2 �A Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ 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 />❑ Pumper Vehicle Registrationti 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 (#of Units) ❑ Dumpsters > 20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />1 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/Oft PROGRAM <br />CONTACTPERSON �iel hSCL. %) ark'r)CZ. Dav Ph „204-d,G1-7_'0dNiaht Ph <br />PROGRAM ELEMENT '.Sbt I FEE_ <br />INSPECTOR#A PERMITVALID <br />n <br />❑ Check # AMOUNT PAID q;e 7,N SrLYJ Date <br />❑ Cash REVIIEEWEED, BAYACCOUNTING OFFICE <br />45-02-034 / /a ((�• I �"' �I �tP� <br />11115/07 <br />❑ Other FEE <br />❑ Food Handier <br />INVOICE # <br />Date 8 / � 2Z <br />MASTERFILE RECORD INFORMATION PINK <br />