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'r SAN JOAQUIN COUNTY ENVIRONNI.ENTAL HEALTH DEPARTME,NT MASTERFILE RECORD"INFORMATION FORM ❑New EH Program at Existing Facility New EH Program and New Facility Facilit ,Zp ® ° 3y - Program Record ID 4 Facility Address —STO E. lel _ J+0 ,,0f) Ci SZUU (Please Check the appropriate description and specify siz , umbe of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units ❑Retail Market---Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only 11Mobile 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 operation from to El ice Plant ❑ Special Event —Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2004) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) a ❑Hazardous Waste Generator.. - Tons Generated Per YearL1Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2218) [1Silver Only(2222) :" ❑ Appliance Reeyclers(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/1lfotel Number of Units ❑Jail or Exempt Institution Number of Units EmPloyeeIlousing(2700)Use Fmployee7-fousinelLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment [I UST-CAP Site ❑Local llW Cleanup Site, ❑NPIJSEP Cleanup Site ❑UIC Site 0 Abandoned IiW Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater Qualify Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility., 111`901 ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds 11 Kennel TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑Body Piercing(4 120) ❑ 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 I Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility 11ProcesslRecycle Facility ❑ CIA-Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing 14arge Generator Q Small Generator ❑Limited hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--El 2-10 ❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PTVS FHD 46-02-003 Blue Applica6arc Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGFL4AtELEh1EIvT �S FEI b� ElSurcliargeFeE © Other FEE INSPECTOR# ��a� PERMITVAL'ID ti 1 1.). to �� 2 ❑ Food Handler_" 1.1 check# AAtOGUPi'r P4.11) — _ Date INVOICE# _ n O 2 ❑ Cash REVIEWED BY JG //Vla ACCOUNTINGOFFtCE Date 7,6 jZ--- _ _t_