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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EHnnProgram and New Facility <br /> Facitit ID 0 t7(�(e(o Pro ram Record IDS31- (-7 ' <br /> Facility Address 1 9,5 i—F. f1 c,fe - La kc <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.} <br /> FOOD PROGRAM(1600) <br /> ElRestauraut: Seating Capacity Square Footage Food Handlers Course required:. Yes 11 No El <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 Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <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 Reeyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pen-nit-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 UST A and P farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units -❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee IIoasin,-Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local MV Cleanup Site, ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IiW Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site "U'Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑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—Registratioa# 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`Paste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility El Compost Facility ❑Process/Recycle Facility 11CIA-LandfillSite <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled"Nursing ❑Large Generator ❑ SmaIl Generator ❑Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-Io ❑ I I-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UscPTVSEHD M-02-003 BlueApplicafiorz Forme <br /> EMERGENCY 140TIFICATION FORTHIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGFL4At ELE14tEIti I FEE Ov2 iJ Surcharge FEE F1Other FEE — <br /> INSPECTOR#� PERMITVALID A. tom/3I /// __ ❑ 1<"oodHandier <br /> _ <br /> ❑ Cheat, _ A MOUNT l'n tip _ . - 'Date ' l 11W010E# 21 Sq t <br /> ❑ Cash R-EVIEwED BY ACCOUNTING OFFICE t� Date <br />