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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP. MASTERFH.E RECORD INFORMATION FORM ❑ New EH Program at Existing Facility MNeW EH Pro am and New Facility Facili! ID U 6 l (03 13 Pro ram Record ID !L -O SaLt c3 Z�-- Facility Address CD11 r',b (,U0-_-s:k ( t f\ k (Please Check the appropriate description and specify size, number of units and pert: FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Mobile Food Vehicle -----Make Vehicle Type_ Registration # License # ❑ Mobile Food Prep Unit --Make Vehicle Type Color Registration # License # Sticker #_ ❑ Temporary Food Facility -----Dates of operation from to ❑ Special Event --Dates of operation from to PAYM V , RECE �R JUL MON'- SAN JQAQUIN,01 60 `l [ �p�VIRONMENTAL 1 ��gALLTH DEPARTMENT Food Handlers Course required: YES ❑ No ❑ ❑ Vending Machines --Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only _ Color Sticker # ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ 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 4S".J n5 ❑ 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 LISTA 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 (412 1) ❑ 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 --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) OK Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- 112-10 ------- ❑ 11- 60 ------❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON PROGRAM ELEMENT INSPECTOR # 0-1 Check # 1 ❑ Cash 48-02-034 10/6/2003 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM � fflosyt 91- Day Ph( a?�.0 6(aal Night] ?/l> FEE 1 zi s PERMIT VALID III �O AMOUNT PAID f? REVIEWED BY " 3 42-ig( � pc�, #e ❑ Surcharge FEE PZ1)114La;,7 ��WOICE 11Other FEE to 3 ❑ Food Handler Date `-1 �— 1 # 13.S28-0 ACCOUNTING OFFICE Date —7 Masterfile Record Pink